In two years covering government for the Topeka Capital-Journal newspaper, Andy Marso has become a familiar presence at the Kansas Statehouse with a reputation for tenacity.
Now, he's written a book that helps explain the source of his dogged determination. It's titled "Worth the Pain: How Meningitis Nearly Killed Me — Then Changed My Life for the Better."
Eight years ago, Marso spent more than four months in the hospital — including horrifying days in a "tank room," where doctors incrementally cut off dying skin and flesh from his feet and hands. He was left with his right thumb and the balls of his feet but lost his fingers and toes. After the cutting came hours and days of intense pain.
The ordeal left Marso shaken, both mentally and physically. The serial amputations forced him to spend months relearning basic tasks such as walking and eating and he grappled with some of life's fundamental questions in the process.
It essentially is a success story centered on answers he found to those questions.
"You are entitled to nothing. But you can accomplish anything," Marso writes in the last chapter.
And he found a deeper faith in God.
"The way I saw it, if God did not exist, then all of this had happened at random. I had somehow won an absurdly awful reserve-lottery and gotten a disease that afflicted a tiny number of people — a disease threatening to rob me of my limbs. I couldn't stomach that. I had to believe that there was a God, and that this was part of his plan for me, even if it did not seem fair."
Unable to get out of bed for months, Marso thought about the things that wouldn't be, such as months or years of carefree fun after graduation living in an already-leased bachelor pad in Kansas City with friends:
"That was supposed to be the place where I would spend a year living with my best friends, playing tennis, watching movies, having barbecues, telling stories and laughing over beers out on the balcony. That was my laid-back and lovely vision of life before meningitis. The first few months of that life already had been stolen and I felt the truth closing in: I might never get back there."
Marso will be signing copies of his book at the Washburn University Holiday Open House. 1 to 2:30 p.m. on Wed. Dec. 4 at Memorial Union, lower level (map)
As the percentage of Kansas children living in poverty continues to climb, the number receiving welfare assistance is falling, according to a new report.
In 2012, more than 23 percent of children lived in poverty — that's up from 21 percent the previous year, according to a report released today by the Topeka-based advocacy group Kansas Action for Children.
The report also indicated that the average monthly enrollment in Temporary Assistance for Needy Families (TANF) had dropped from nearly 26,000 in 2011 to about 21,600 in 2012.
In 2007, there were also about 21,000 Kansans receiving TANF, but in that year only 18 percent of children were living in poverty.
The poverty line for a family of four is about $23,000 a year.
“Many Kansas families haven’t yet rebounded from the recession. These are working parents who aren’t able to earn enough to make ends meet — they need these programs to help them feed their children and keep them healthy and safe,” Shannon Cotsoradis, chief executive of Kansas Action for Children, said in a prepared statement accompanying the report.
“And yet the Department of Children and Families (DCF) continues to make administrative changes without legislative oversight or consideration for the impact on families. It’s time to reverse course.
“The greatest threat to the well-being of children is a lack of economic security,” said Cotsoradis. “Making it more difficult to access safety-net programs only hurts our chances of reducing poverty.”
Among the administrative changes cited by Cotsoradis were:
- More work and job training requirements for TANF,
- Requiring new mothers to return to work after two months — instead of six months — to receive TANF aid,
- Reducing the lifetime limit on TANF benefits from 60 months to 48 months,
- Changing the way household income is calculated to qualify for foodstamps,
- Eliminating funding for programs that spread awareness of foodstamp availability,
- Separating the application processes to apply for TANF and for Medicaid.
The state has also instituted new drug screening for TANF and has stepped up fraud detection.
And last week, Gov. Sam Brownback proposed diverting about $18 million from TANF — which typically consists of cash payments to families — to help pay for a new reading initiative.
‘Helping adults achieve self-sufficiency’
Theresa Freed, spokeswoman for DCF, said the agency "is making every effort to reduce childhood poverty" by helping families find work.
"Previous efforts to reduce poverty by eliminating work requirements have proven ineffective in helping Kansas families. It is a top priority to help adults achieve self-sufficiency so that they can meet their own needs and those of their children," Freed said in an email.
"We understand that some jobs do not pay enough to make ends meet. That is why we have various assistance programs available and with job training through our state partners, families can achieve complete self-sufficiency," she said.
She said the reading program also would help reduce poverty by providing children the skills they need in the workforce.
"The Reading Roadmap programs that are supported by TANF funds are strictly for out-of school literacy efforts. This is again, to encourage the prevention of the cycle of poverty. By empowering young people with the tools they need to succeed later in life, we are supporting the objectives of the federal TANF program," Freed said.
Officials have said another goal of the reading program is to reduce teen pregnancies.
"A 2012 study by Dr. Ian Bennett at the University of Pennsylvania found that seventh grade girls with a less-than-average reading skill were 2.5 times more likely to have a child in their teen years compared with those with average reading skill," Freed said.
The Kansas Medicaid program seems to be catching up with the rest of the nation when it comes to dental care for children.
In the past dozen years the state has doubled the number of Medicaid children receiving dental services, said Kamyar Nasseh, an economist from the American Dental Association. Nasseh spoke at the Oral Health Kansas conference held here last week.
Nasseh said about 20 percent of Kansas children on Medicaid logged a dental visit in 2000. But in 2012, that figure was up to 40 percent, he said, citing statistics from the federal Centers for Medicare and Medicaid Services.
One explanation for the greater percentage of Kansas Medicaid children seeing a dentist could be the state’s school-based screening and sealant program, said Jennifer Ferguson, manager of the Kansas Children’s Oral Health Program. The program targets low-income students.
The program screened approximately 154,000 students during the 2012-2013 school year, more than double the number served just three years prior, according to a presentation by Ferguson.
But despite the improvements, the Kansas percentage remains slightly below the national average, Nasseh said.
Yesterday, KHI News Service reported that Kansas’ Medicaid-reform program, known as KanCare, had effectively shut down a grant-funded initiative that provided Medicaid dental services to children in Head Start programs.
Nasseh gave the keynote speech at the two-day conference, which drew about 160 people. It was held at Johnson County Community College.
Nasseh cited other Kansas figures:
Approximately 49 percent of low-income adults saw a dentist in 2010, down from about 53 percent in 2002. There was a similar decline in the national percentage.
Assuming full implementation of the federal health-reform law, approximately 545,000 Kansas children would have dental benefits by 2018, a roughly 16 percent increase over 2010. A key requirement of the law is that private health insurance plans must include pediatric dental and vision benefits starting next year.
The Medicaid reimbursement rate for dental services is less than half (46.9 percent) the commercial payment rate, which is about in line with the national average of 50.3 percent.
And he described a national survey by the dental association that found that more than a third of dentists reported they were not busy enough and could accept more patients.
Conference presentations are available online, along with the first-ever county-by-county oral health snapshot of the state, which was produced by Oral Health Kansas and released at the conference.
90 percent of counties short on dental providers
Tanya Dorf Brunner, executive director of Oral Health Kansas, said she was surprised to hear that given that 95 of Kansas’ 105 counties do not have enough dental providers.
Members of an oral health task force established by the Kansas Board of Regents recommended last year that the state open a dental school to help address the shortage.
The disconnect between the findings in the dental association survey and the Kansas statistics could boil down to differences among safety-net providers and private-practice dentists.
If state-run Medicaid had its problems, one part that was working well in Kansas was providing oral health care to kids through programs such as Kansas Cavity Free Kids, Head Start officials say.
By the fifth year of the pilot program, which began in 2007, more than 7,000 children in 41 rural counties had received regular cleanings, fluoride varnishes and sealants from dental hygienists in Head Start classrooms.
It worked so well that program officials planned to expand it to other areas of the state where access to dental care is chronically limited.
But the program was effectively shut down after the launch of KanCare on Jan. 1, when day-to-day management of the state's Medicaid program was turned over to three for-profit managed care companies.
UnitedHealthcare, one of the state’s three KanCare contractors, chose to not authorize payment for teeth cleanings performed at Head Start, a decision that effectively put the entire program on ice.
"United does not recognize (a hygienist's) services if she's working under Head Start for doing cleanings for kids or for pregnant women," said Kathy Hunt, the Head Start official who coordinated Kansas Cavity Free Kids.
The other two KanCare companies — Amerigroup and Sunflower State Health Plan, a Centene subsidiary — continued the previous state policy of allowing dental care performed at Head Start facilities to be billed under Medicaid.
But Hunt said the program could not continue serving children covered by those companies while turning away others covered by United.
"Quite frankly, we have not provided services since" KanCare began, Hunt said. "We can't say 'I'm going to provide services for this child and not for this child.'"
Hunt also serves on the board of directors for Oral Health Kansas. She testified about the problem last month at the first meeting of the Legislature’s KanCare oversight committee.
A month later, she hadn’t had any response from legislators, state officials or representatives of UnitedHealthcare.
A state senator says he’s working on a bill that would give some foster parents more say in the legal process for determining whether children in their care should be returned to their biological parents or put up for adoption.
“It seems to me that foster parents are the ones who spend the most time with these kids, but they have no authority, no power,” said Sen. Forrest Knox, an Altoona Republican. “They’re just babysitters.”
Knox said he plans to propose creating a “new tier” of foster parents who would be allowed to participate in the decision-making process in exchange for being better trained and taking on more difficult children.
“We’d expect a lot more out of them, but we’d pay them a lot more, too,” he said.
Knox and his wife, Renee, have nine biological children, two of whom still live at home. The couple adopted four brothers — then ages 5, 7, 8 and 13 — two years ago after caring for them two years as foster parents.
Too little say
Knox said he thought more “good people” would agree to become foster parents if they knew they “would be given the tools to make a difference in kids’ lives.”
Many compassionate adults, he said, don't become foster parents because they know they would have little or no say in what happens to the children placed in their care.
“The kids get jerked out of their homes and they’re not told why,” Knox said. “They have no standing. They’re just a place to put kids.”
Knox said his proposal would not increase overall costs.
“I’m looking at spending less money total,” he said, “but spending it more effectively.”
In Kansas, foster-care decisions are the subject of court proceedings during which a judge rules on evidence presented by attorneys representing the state, the children, and the biological parents.
Foster parents are allowed to file written reports with the court, letting the judge know how the children in their care are faring. But they are not considered an ‘interested party’ with legal standing in the case.
Decisions affecting the services children receive while in foster care are made by the Kansas Department for Children and Families, which contracts for services with two nonprofits: KVC Behavioral Health and St. Francis Community Services.
St. Francis and KVC, in turn, each have networks of licensed foster homes. They also rely on networks developed by other charitable organizations.
'A lot of inefficiencies'
Kansas privatized most if it’s foster care responsibilities in 1996.
“I haven’t seen (privatization) really work,” Knox said. “I see a lot of inefficiencies.”
According to the latest reports on the DCF website, 5,780 children were in the state’s foster care system last month. Currently, the system includes 2,546 licensed foster parents.
Knox said he hoped his proposal would be the subject of a pilot project somewhere in the state next year.
Bruce Linhos, executive director with the Children’s Alliance of Kansas, an advocacy group that helps train foster parents, said similar proposals similar have been tried in the past with varying degrees of success.
All of the foster care contractors and subcontractors, he said, have foster parents who have more training than most and who are willing to take on children with especially difficult behaviors.
“That kind of family has always been around and they’re of huge value,” he said.
Still, Linhos said, Knox’s proposal appears to be “entirely plausible” in light of an ongoing effort to lessen the state’s reliance on residential facilities for mentally ill children. He said it might also complement a recent Office of Judicial Administration initiative aimed at helping parents and children better navigate the foster care system.
Marcia Allen, who runs Kansas Family Advisory Network, a Wichita-based group that advocates for parents whose children are in state custody, said Knox’s proposal would raise several issues that have proven to be contentious in the past.
“I fully support more training for foster parents and I understand that they want more say in the process," she said. "But is that to say they should have more say than the birth parents? Should they have more say than the children? And what about grandparents? Shouldn't they have a say? Everybody wants more say in the process. And you know what? They all probably deserve more say.”
The Health Care Foundation of Greater Kansas City has rolled out a new website designed to be a comprehensive source of health information for a six-county region in Missouri and Kansas.
The website KCHealthMatters.org has about 150 data indicators, and it allows users to analyze information down to the census tract.
“And it’s more than just numbers,” said Sarah Hurd, an analyst with the Kansas Health Institute, which helped develop the site. “There is a focus on action.” (The institute is the parent organization of the KHI News Service.)
In a presentation Wednesday, Hurd pointed to the “promising practices” portion of the site, which includes reports from local, national, and international sources. Users can submit their own promising practices.
The site covers the Health Care Foundation service area: Cass, Jackson and Lafayette counties in Missouri, and Johnson, Wyandotte and Allen counties in Kansas.
Officials involved with development of the site said they hope it can help the social service community in applying for grants. But, they said, it’s also meant to be a resource for a variety of users, including providers, government officials and the general public.
The website should prove to be a “wonderful tool” for the community, said Gretchen Kunkel, president of KC Healthy Kids, a nonprofit dedicated to reducing childhood obesity.
She said nonprofit officials are always looking for data.
“Data to help us tell a story of what (is) happening in the community, data that help us understand how we can apply limited resources, and data to help us create understanding and collaboration to bring those resources together so that we can realize a healthier community,” she said.
The site is similar to KansasHealthMatters.org, sponsored by the Kansas Partnership for Improving Community Health, a collaboration that includes nonprofit, government and university partners.
Perhaps it is a case of could-have-been.
Two years ago, Gov. Sam Brownback rejected a $31.5 million federal grant to set up a health insurance marketplace tailored for Kansas — defaulting instead to the federally run exchange that was launched Oct. 1 but which continues to be beset by problems.
Gary Schneider — the technology expert who was poised to lead Kansas' marketplace development until Brownback opted against it — left instead for Colorado, one of 16 states that chose to run their own marketplace. He now is the IT project manager for the Colorado Health Benefit Exchange.
In Colorado, so far, things are going smoothly, Schneider said.
More than 700 people have enrolled in insurance plans using Connect for Health Colorado, the state’s marketplace. And more than 30,000 people have created accounts on the website allowing them to compare plan options and see if they qualify for tax subsidies.
"We had some bumps in the road with our system when we first turned it on, but most of those have been resolved," Schneider said.
Like the federal marketplace, Colorado's website initially was overwhelmed with traffic.
"Until you turn a system like this on ‘live’ and experience a real load, you can't be sure how it's going to react," Schneider said. "That was the first couple days, but things got pretty stable pretty quick."
CGI, the contractor that built the Colorado marketplace, also built the federal exchange. But Schneider said the fact that so many states went the way of Kansas — opting to use the federal marketplace, HealthCare.gov — greatly complicated the task for the national government.
"If they had anticipated 35 or so states being in the federal marketplace, I'm sure they would have done some things differently,” he said. “But that just panned out in the last 18 months, where states made these decisions to opt out. I don't think they anticipated more than a handful of states to be in the federal marketplace.”
Schneider said he wasn't surprised that the federal marketplace is off to a rocky start “given the tight deadline and the fact that so many states opted to not have a state-based marketplace. That made their task extremely challenging...because there are business rules that apply to different states."
President Obama today held a press conference to reassure those frustrated with HealthCare.gov, saying that "nobody is more frustrated by (the glitches) than I am."
But, said Obama, "even with all the problems at HealthCare.gov, the website is still working for a lot of people, just not as quick or efficient or consistent as we want."
That complexity has been the federal marketplace’s undoing so far, said Timothy Jost, an expert on the health reform law and a professor at Washington and Lee University School of Law.
"The main culprit is just a very, very complex system that must be established to enroll millions of people in hundreds of different health plans," Jost said. "The fact that 36 states refused to participate I think was completely unexpected. And Congress has not appropriated funds — since the initial appropriation, that I know of — for the federal exchange," he said, referring to the federal marketplace.
"Instead Congress has held numerous hearings that have tied up key government officials and kept them from getting their job done. So I think Congress is probably more to blame than anybody else."
Jost also laid blame on "the states that have opposed implementation, including Kansas."
“The states' decisions to not run their own exchanges has had a very serious effect,” he said. “States that are running their exchanges are showing a lot of success.”
States including Hawaii, California and Colorado experienced problems in the opening days of their marketplaces, but according to most reports those have now been largely resolved.
Switching to a state-based marketplace
Should Kansas change direction and decide to run its own insurance marketplace — which for now seems unlikely given the opposition to Obamacare among the state’s Republican leaders — it could have the option of implementing proven software, such as that running Colorado's marketplace.
Schneider said he is in talks with several other states about using the system Colorado built, but Kansas isn't among them.
State lawmakers' resistance to expanding Medicaid “just makes no sense,” Kansas Insurance Commissioner Sandy Praeger said Thursday, speaking at a meeting of safety-net clinic officials.
Many legislators, she said, “really don't understand” the consequences of not expanding Medicaid because there was “almost no discussion of the Affordable Care Act” during this year's legislative session.
Praeger, who has been hosting a series of informational forums on the health reform law for the past three weeks, said legislators will have a hard time not addressing Medicaid expansion in 2014.
“People are starting to understand what the lack of Medicaid expansion means,” she said. “And I think legislators are starting to hear from them.”
Currently in Kansas, non-disabled adults with children are eligible for Medicaid if their incomes fall below 32 percent of the federal poverty level, roughly $6,250 a year for a family of three.
“Let me put that in perspective for you,” said Health Reform Resource Project Director Sheldon Weisgrau, who also spoke at the annual conference of the Kansas Association for the Medically Underserved. “That means that a mother with two kids who works a minimum-wage job half-time makes too much money to be on Medicaid,” though the children would qualify.
Childless, non-disabled adults, are not eligible for Medicaid “under any circumstances,” he said.
Under the Affordable Care Act, commonly known as Obamacare, the federal government will cover all or most of the costs of expanding Medicaid to include adults whose incomes fall below 138 percent of the poverty level. However, expansion is optional and up to the political leaders in each state.
Low-income children and pregnant women already are covered under Medicaid.
In Kansas, Medicaid expansion would insure about 130,000 adults who are currently uninsured, according to various estimates.
Gov. Sam Brownback and the Republican majorities in both the House and Senate have shelved the Medicaid-expansion debate, saying they doubt the federal government will be able to keep its promise to cover most of the costs.
Cost of expansion
If adopted, Medicaid expansion would cost the state about $625 million over 10 years, according to a projection by the Brownback administration.
“To put that number into context, last year the State of Kansas spent $1.2 billion in state money on Medicaid,” Weisgrau said. “This increase of $625 million is over 10 years, but the Legislature decided we could not afford that.”
The administration's calculation, he said, did not include the offsetting costs to local programs — county health departments, safety-net clinics, hospitals — for covering the needs of the uninsured.
With millions of Baby Boomers at or approaching retirement age, university and city leaders here are looking at building from the ground up a new type of “intergenerational” neighborhood that they say could become a model for other college towns along the Interstate 70 corridor in Kansas and Missouri and perhaps spark a new approach to the way the aging process is studied and the resulting research is applied everywhere. Right now, most retirement centers or senior living developments in Kansas, Missouri and elsewhere in the U.S., are age-segregated, which means only old people live in them. But Dennis Domer, a University of Kansas architecture historian who is spearheading the New Cities initiative here, and others, say the predominant, current model doesn’t work well and it’s time to change it.
What Boomers want
“That doesn't work socially or economically and it isn't what the Boomers want,” Domer said. “They don't want to go someplace to die, they want to go someplace to live” in a way that doesn’t leave them “slowly trailing down the misery curve the last 10 years of life.” After three years of research drawn from various disciplines, the conclusion reached by Domer and others involved with New Cities is that most of the nation’s 80 million Boomers, those born between 1946 and 1964, want the following things in retirement, if not sooner:
- Proximity to nature
- Children, grandchildren and friends nearby
- Walk-able neighborhoods
- Continuing education opportunities
- Access to good health care and transportation
- Affordable housing
In addition, they want to leave a legacy, such as mentoring younger people and they don’t want to live out their days among only their contemporaries – they want to be surrounded by people of various ages. An off-shoot of the New Cities initiative is a planned residential development that Domer describes as a potential “living laboratory” for creating the optimal neighborhood for aging Boomers and for researchers to study the various effects and aspects of aging.
Called Campus Village, the proposed development would be on 60 acres in west Lawrence contiguous with the soon-to-be-built Rock Chalk Park, a $39 million sports complex being built by the KU athletics department with help from the city.
→ Continue reading at khi.org/newcities.
Some 27,000 people in Wyandotte County have no health insurance. Health officials are hoping Obamacare and the new insurance marketplace expected to be operating soon in Kansas can help change that.
“We assume quite a few (of the 27,000) are going to be able to qualify” for subsidies through the marketplace, said Joe Connor, director of the Unified Government of Wyandotte County Health Department.
The marketplace, which federal officials have pledged will be ready to launch on schedule Oct. 1, is aimed at making affordable health coverage available to thousands of Kansans who otherwise might not have it.
Nationally, the state marketplaces — also sometimes called insurance exchanges — are expected to serve millions of Americans and are a key component of the Affordable Care Act, which became law in 2010.
‘Misinformation and polarization’
Officials here have a task force that earlier this month began planning ways to get the word out about the exchange to some of the people considered most likely to benefit from it.
The panel is part of the Healthy Communities Wyandotte initiative and is chaired by former Kansas Medicaid Director Barb Langner. She now works at the University of Kansas Medical Center but is working on the initiative as a volunteer.
Langner said the group doesn’t want to duplicate public-awareness work that will be done by others, including the federal government and the Kansas Insurance Department, but that a local touch is needed if everyone in the county is to be reached.
“This is a county that's used to creating some local solutions,” Langner said. “I think the statewide (public outreach) effort will be all well and good, but there are some pockets of people you will not reach unless you have local involvement. A lot of people are not going to go to a public meeting about this. It has to be a little more user friendly.”
Langner said the task force hopes to provide easily understandable information about the exchange to people who already are trusted in the neighborhoods so they can disseminate it to likely exchange users.
“I think because of the misinformation and uncertainty and sort of the polarization on this topic, it’s going to take someone who is trusted to explain it. And you're going to be dealing people that most likely don't have a lot of familiarity with insurance products, so I think personal contact with someone they trust will be important,” Langner said.
“Our role is to get whatever information has been produced to the people who have the contacts in the community. The logical places are churches, perhaps daycares, schools, small businesses, salons. We’re still in the planning phase right now,” she said.
Little time left
Whatever the group does will need to happen soon, because Oct. 1 is looming. The coverage plans offered through the marketplace become effective starting Jan. 1, which isn’t too distant in time, either.
Kansas Medicaid officials are preparing for a new phase of KanCare that will target services to the seriously mentally ill.
They will be using a “health home” model that appears to be producing good — though preliminary — results in other states and which will allow Kansas to draw additional federal aid dollars as part of the Affordable Care Act.
Among the goals of federal and state officials in using the model is to reduce emergency room visits and hospital readmissions among Medicaid enrollees.
The Kansas Medicaid program — which was rebranded as KanCare at the beginning of 2013 when virtually all 380,000 enrollees were moved into commercially run managed care plans — is scheduled to begin health home efforts on Jan. 1, 2014, and will direct them at about 36,000 of the state’s seriously mentally ill, though participation is voluntary.
A health home is not so much a place as it is a concept of care delivery built on close coordination among a patient’s various medical providers so that health crises can be prevented or minimized through better management of a person’s conditions.
The mentally ill are disproportionately likely to also suffer other chronic conditions.
“They (federal Medicaid officials) expect fewer emergency room visits, fewer readmissions to inpatient settings and, of course, they also want to see lower costs,” said Becky Ross, Medicaid initiatives director at the Kansas Department of Health and Environment, the state’s chief Medicaid agency. “There are some things they will require all states to measure and then we have some additional things we’ll be measuring.”
Kansas officials are in the process of developing a state Medicaid plan amendment, which Ross said they would formally submit to federal authorities in October after earlier submission of a draft document. And they plan to consult with federal mental health officials on the plan before Aug. 2, Ross said.
Work on the Kansas health home initiative began in April 2012, when a team of state officials began meeting about it. That quickly grew to include a “focus group” of about 70 people who work with the Medicaid program as providers or as association representatives.
And Tuesday, at least 200 people are expected for a forum in Topeka where Ross said state officials hope to collect additional information from potential health home providers so that finishing touches can be put to the state’s plan amendment. An earlier forum was held in April and Ross said Tuesday’s gathering would be the final one.
WICHITA — After opposing the move for nearly two years, many providers of long-term services for the developmentally disabled say they now are largely resigned to the state’s plan to fully include their system in KanCare. But that doesn’t mean all the questions and worries about the proposed changes have gone away.
Chief among them seems to be this: How will the whole thing work?
“There was that whole debate this past (legislative) session and last year’s session about whether it’s good for people with DD to be in this (KanCare), but that debate is behind us now,” said Jerry Michaud, president of Developmental Services of Northwest Kansas, Inc., (DSNWK) a nonprofit Community Developmental Disability Organization that serves about 500 developmentally disabled, or DD, people in the state’s 18 northwestern-most counties.
“And so now, it’s how do we set up a system that's going to work and not wait until the first day to realize there are some major hiccups,” Michaud said.
State officials this week are holding two public hearings on an application they plan to file with federal authorities, probably in mid or late August, seeking approval for the KanCare expansion and some other Medicaid program changes.
The second of the two public comment sessions is set for 10 a.m. Tuesday in the Madison Ballroom at the Downtown Ramada Inn in Topeka (map).
However, state officials said they believe they already have all the authority they need for the so-called “DD carve-in” as a result of the initial federal sign-off on KanCare in December 2012, just days before the KanCare initiative was launched on Jan. 1.
Kansas officials said federal officials have been urging states to broaden their Medicaid managed care programs so that various services can be better coordinated. And key spokespersons for the state's developmentally disabled service groups said they don’t expect the federal Centers for Medicare and Medicaid Services to block the expansion once they receive the state’s Medicaid waiver request.
But there are a number of key questions about how the changes scheduled to begin Jan. 1 will be accomplished and whether or not some of the problems experienced by KanCare providers in the past few months will have been smoothed out so that the new expansion is relatively easy or seamless for the developmentally disabled and those who assist them.
State officials have said for two years that they intend to leave the current, time-honored service delivery system in place. But the nature of the working relationship the providers will have with the state’s three KanCare contractors and their myriad subcontractors is still being sorted out.
“We are meeting two times a week with the MCOs (the KanCare managed care companies) and the different provider work groups to make sure we get this correct and to make sure we have this exactly correct the first time out,” said Aquila Jordan, director of Home and Community Based Services for the Kansas Department for Aging and Disability Services (KDADS), the agency that oversees the state’s Medicaid DD programs.
Gov. Sam Brownback’s Medicaid makeover has been putting a financial squeeze on small Kansas pharmacists and spokespersons for the hometown druggists are calling for the administration to enforce the terms of its contracts with the three KanCare managed care companies.
“I think the simple answer is for the State of Kansas to make sure the MCOs (KanCare managed care companies) are living by their signed contracts and that should have been ready to go Jan. 1 (when KanCare was launched),” said Mike Larkin, executive director of the Kansas Pharmacists Association.
“We understand there will be bumps and hiccups in the implementation of a new program, but I can't help but think that if the shoe was on the other foot and they (the MCOs) were losing money instead of making money, they would have been on this (problem) a lot quicker,” he said.
Pharmacists say the heart of the issue is that the KanCare companies — Amerigroup, UnitedHealthcare and Sunflower State Health Plan — often fail to reimburse the druggists for the costs they incur serving Medicaid enrollees.
“I guess the bottom line is that we were led to believe in the first year (of KanCare) that there would be no changes on reimbursement or anything,” said Ron Booth, owner of the Corner Pharmacy in Leavenworth. “But you see, these (KanCare MCOs) are for-profit companies. They are changing all the rules and no one in Topeka is holding them accountable. I'm speaking out of frustration as a small, locally owned pharmacy. I want to be treated fairly.”
The pharmacists, before and after KanCare, work from rate sheets that list the maximum they will be reimbursed by Medicaid for each of the long list of medications they dispense.
But here is what changed with KanCare, according to pharmacists and others familiar with the business: In the past, the state kept a single list or rate sheet of “maximum allowable costs” and when its reimbursement rates failed to cover a druggists’ costs, it was more or less routine for the pharmacist to appeal and have the rate revised upward. The druggists could then resubmit those claims to the state and be paid enough that they weren’t losing money on the transactions.
With KanCare, each of the state’s contractors — or rather their pharmacy subcontractors — keeps a separate rate sheet, the formulation of which is considered proprietary. Booth and others said getting prices adjusted by the MCOs, so that the pharmacists aren’t losing money on many of their Medicaid claims, has largely been an exercise in futility. And they also are frustrated that they can’t get access to the methods the MCOs use for calculating their reimbursement rates, something obliged of them in their contracts with the state.
Customers turned away
Booth’s pharmacy, which was established in 1871, still has a soda fountain and other small-town amenities of a largely bygone era. It is a hub of activity in the middle of Leavenworth’s historic downtown district and Booth is a proprietor clinging to and clearly relishing his role in the vanishing tradition of local merchant as “pillar of the community,” in daily contact with his customers and their concerns.
Booth said since KanCare started he has served hundreds of his customers at a loss and turned away more than that because he could no longer afford to fill their prescriptions. And he said he has not had a single appeal approved or adjusted upward by any of the KanCare companies since the program started six months ago. He gets form-letter denials, he said, and little or no understanding from the KanCare customer service reps when he calls to complain or ask for assistance.
“My problem is I'm dealing with real people in front of me at the counter,” he said. “They are my friends and neighbors. I actually care about them.”
Reviewing the appeals data
State officials said they were aware of the pharmacists’ concerns with reimbursements (outlined in a May letter from Larkin to KDHE) and were looking into them.
“KDHE has heard provider concerns that fewer MAC (maximum allowable cost) appeals are being approved in KanCare than in fee-for-service Medicaid,” said Kari Bruffett, director of KDHE’s Division of Health Care Finance. “KDHE is in the process of reviewing both KanCare MAC appeals data in aggregate and a sample of denied appeals to ensure compliance with our expectations.”
Meanwhile, Bruffett said, the state’s overall pharmacy spending was up from last year.
“Through the first five full months, overall pharmacy reimbursement is running about 8 percent ahead of the same time period in 2012,” she said in an email to KHI News Service.
“Someone probably is benefiting,” from KanCare, Booth said, but it hasn’t been him.
In fact, you probably shouldn’t get him talking about it unless you have some time to listen.
“At first, we were just absorbing the cost. But I decided I'm not going to do it anymore,” he said. “I'm going to be the squeaky wheel. Someone's got to stand up. I don’t want to subsidize these big MCOs that make millions each year. I work about 70 hours a week. I’m fighting for my life everyday. The big boys don’t need me. They don’t need Ron Booth who gets up in the middle of the night for his patients, sees them at Rotary, sees them at church, goes to the ballgames. I’m part of this community and unfortunately I have a conscience.”
Ben Alexander grew up in Shawnee, but you wouldn’t always find him there.
More likely, he’d be exploring in Kansas City, Mo., checking out the rural parts of the area, or heading to the Kansas River.
“I would ride my junky little bike all over the place,” he said, “and it got me in shape, kept me out of trouble and got me around the city.”
Alexander went on to graduate from Shawnee Mission Northwest High School in 2006, and four years later he emerged from the University of Kansas with undergraduate degrees in environmental studies, geography, international studies and Spanish.
Now, at age 25, he’s working to help underprivileged children learn and grow through biking like he did as a kid.
Alexander is founder and executive director of a nonprofit called FreeWheels for Kids, which is based in a spare bedroom of the house he and his wife own in the Strawberry Hill neighborhood here.
FreeWheels for Kids teaches bike safety to children as young as age 8.
Through the FreeWheels Earn a Bike program, middle school- and high-school can learn bicycle repair skills as they refurbish donated two-wheelers for themselves and other children. Alexander also tries to teach the students the benefits of mastering new skills and taking on big jobs.
It’s about having the confidence to look at a broken down bike, Alexander said, and being able to say, “Yeah, I can take this on. I’m going to make this happen.”
Alexander started the program in the fall of 2011 while working as a part-time paraprofessional in a Kansas City, Mo. charter school. He officially incorporated the enterprise as a nonprofit corporation early last year.
Within the last couple of years, he said, participants had refurbished approximately 450 bicycles.
The nonprofit received a grant earlier this month from the Health Care Foundation of Greater Kansas City. Alexander said that funding would go toward establishing bike clubs in conjunction with the Earn a Bike program.
In addition, the Bethel Neighborhood Center, located along Seventh Street near Central Avenue here, has earmarked about one fifth of a $50,000 grant it received to expand FreeWheels for Kids programming there. That grant was part of funding announced last month from the Unified Government of Wyandotte County/Kansas City, Kan.
The two grants, Alexander said, were a big reason why the nonprofit has a cash budget of about $60,000 this year. Last year’s cash budget was only about $5,000.
Alexander said the nonprofit was on track to serve about 900 children this year.
On Wednesday, Alexander was assisting Earn a Bike participants in the basement of the Bethel center.
On one side of the room, 12-year-olds Reyna Espino and Jaquelin Arambula worked to get the back tire off a pink Barbie bike propped upside down on its seat. Their workstation was a ping-pong table.
Eduardo Cruz, 12, sat nearby on a metal folding chair dealing with a tire issue of his own.
Reyna said the bike-repair skills she had learned could come in handy.
“If anything went wrong with my bike now,” she said, “I would know what to do with it besides putting it in the trash.”
Both girls said that working on bikes had taught them the benefit of patience. They also said it felt good to repair bikes that someone else could use.
Eduardo said what he had learned through FreeWheels made him feel safer riding his bike around the neighborhood, which he said he liked to do “because it is exciting and gets us in shape.”
The Rev. Mang Sonna, executive director at the Bethel center, said he wanted to work more with Alexander because he liked Alexander’s rapport with the children.
Evidence of that, he said, was seeing the Bethel center children riding around the neighborhood on the bikes they had fixed up in class.
It’s especially important to stress physical fitness for kids at the center, said Rakmi Shaiza, program director and volunteer coordinator, since most of them come from families with no health insurance.
Parents also realize the benefits of the program, she said. A lot of them work, she said, making it difficult for them to come to the center to register their children for things.
But “with this program, almost all of them immediately came to sign up,” Shaiza said.
→ Find ongoing coverage of issues that affect the health of Kansans at khi.org.
The big push by federal officials to get the word out in the next few months about the Affordable Care Act mostly will bypass Kansas, but even in this generally anti-Obama red state there are organizations and community groups gearing up to inform the public about the new health insurance exchange scheduled to launch on Oct. 1.
“I think that there's a lot of misunderstanding about what the Affordable Care Act is and how it works and there's so much noise from a political perspective that people can't really focus on what it is they need to know” about it, said Roberta Riportella, a professor of community health at the Kansas State University Extension. “What we're going to try to do is cut through that noise.”
Riportella has been on the job at K-State for about three months and for at least the next several will be spearheading an effort to use county extension agents and faculty members to inform the Kansas public about the federal health reform law, particularly the new insurance exchange through which millions of Americans and hundreds of thousands of Kansans are expected to purchase their health coverage.
The extension is a long-trusted K-State institution with agents working in all 105 counties. They do all sorts of things to help people, ranging from counseling on best farming practices to helping seniors enroll in Medicare Part D drug programs. They teach 4-H kids to make jelly and other skills, give parents tips on home economics, and are the state’s most persistent crusaders against musk thistle and other noxious pests.
Over the next several weeks, including as part of their annual training sessions in August in Manhattan at the K-State campus, the agents will be learning details of the Affordable Care Act and how to communicate its meaning to the people intended to benefit from it.
In at least one county, (Shawnee, home of Topeka), there will be as many as three extension agents working to get out the word.
They and their colleagues across the state will be trying to inform a public that still knows relatively little about the law three years after it was passed. A recent poll by the Kaiser Family Foundation showed that most Americans still don’t know much about the law commonly referred to as Obamacare.
“I think it will take a big educational effort and I don't expect everybody to get it by the deadline,” said Cindy Evans, a K-State extension agent who works in Shawnee County. “We'll just have to keep working at it and hopefully, if it turns out to be a good thing, people will tell their friends and family about it. It won't be just an agency like (extension) carrying the message. You’ll need community connections, churches and other groups letting people know.”
Each year for the past six, Evans said, she has worked one on one with seniors to help them enroll or re-enroll in the Medicare prescription drug program. But she said it would be impossible to work individually like that with people on the Affordable Care Act simply because of the thousands expected to use the insurance exchange.
'Keep politics out'
Sue Peterson has served for years as K-State liaison to the Kansas Legislature and she knows very well the revulsion the state’s elected conservative Republicans have for Obamacare. Gov. Sam Brownback campaigned for the job pledging to fight the law "every step of the way.”
“It was envisioned by the United States Congress when they passed the Hatch Act and Smith Lever acts, (that) research and extension would provide information to the public who needed or wanted information. The university, and research and extension provide unbiased scientific research findings or information to the public at large around the state,” Peterson told KHI New Service in an email when asked if she expected the university to face political repercussions at the Statehouse because of extension agents doing their jobs.
Evans said she didn’t want her efforts to be misconstrued as political.
“I think extension's role is going to be what it always been — education,” she said. “I don't want to be political at all on this. I just want to keep politics out. People have feelings on both sides on whether they think it will work or cost the system too much. It’s not my role in extension to be political. My role in health literacy and senior health counseling, is to just accurately help people understand the law as it is today.
“I’m not trying to take a stand whether it’s good or bad,” Evans said. “My major area is family finance and people spend a lot of money on insurance and health care and I want to help. My role in family finance is to help them make a good financial decision and not be political.”
Federal officials are preparing for a major public awareness campaign to be most evident in August and September that in some ways has already started. Today, for example, the U.S. Department of Health and Human Services announced a new website and a telephone call center in anticipation of the Oct. 1 exchange launch.
But the major focus of the marketing blitz by the feds and national health consumer groups is expected to be in states with high numbers of people without health coverage, including California and Texas.
Kansas is among the states where federal officials will run the new health insurance exchange but the state’s top insurance regulators said they hope to inject a local flavor.
Insurance Commissioner Sandy Praeger said her agency has been in discussion with the feds about having some of the more complex calls to the exchange’s toll-free helpline roll over to her department so that Kansas consumers come in touch quickly with local people more familiar with the Kansas insurance plans offered in the exchange and the governing regulations.
“We’re discussing how we can make a quick, relatively seamless transfer,” of appropriate calls to the Kansas Insurance Department, Praeger told KHI News Service.
“Our expectation is if you call the 800 number and if you have really simple questions like ‘I don't think I have the proper web address for the exchange or my password isn't working,’ a very operational question, they would handle it,” said Linda Sheppard, the insurance department’s director of health care policy and analysis. “But if it’s questions specifically related to anyone's benefits or coverage, those would be forwarded to us.”
The department already routinely fields calls from consumers with complaints about denials of insurance claims or delays in processing, so it only makes sense to carry that practice forward with implementation of the Affordable Care Act, Praeger said.
The exchange or marketplace is scheduled to be operational in each state by Oct. 1 with coverage purchased through the exchange effective Jan. 1.
'Hiccups along the way'
Some Republican officials have questioned whether the exchanges will be up and running by Oct. 1. Praeger, who has been generally supportive of the new law, is not among them. But she predicted it wouldn’t be a smooth start.
“Oh, I think they'll be up and running,” she said. “There will be some hiccups along the way. That's putting it mildly, especially if you look at how the Medicare prescription drug program rolled out in the Bush administration and this is much more complicated.”
→ Related story: Kansas insurers gearing up to market new plans on exchange
School administrators here say they are alarmed and confounded by the looming, new costs they face with the implementation of the Affordable Care Act.
“We've been talking about it (in anticipation) the last two years. I wish there was somebody smarter than me to find a solution,” said Chris Hipp, director of the North Central Kansas Special Education Cooperative Interlocal 636.
“We are not built to pay full health benefits for non-certified folks who work a little over 1,000 hours a year. I've spent hours and hours running every possible scenario. We can't pay for any of them, so it’s all kind of an academic effort really," he said.
As part of the federal health reform law, commonly referred to as Obamacare, larger employers across the country have a new set of insurance coverage obligations and fees they must pay. The new rules apply to commercial enterprises with 50 workers or more but also to public employers such as cities, school districts and the state of Kansas.
Kansas officials estimate the new fees alone will cost the State Employees’ Health Benefit Plan at least $4.7 million in 2014, or about $63 per worker. That’s without reckoning the added costs of the law’s new coverage requirements, much of which the plan already is absorbing.
For many businesses and larger governmental units, the new obligations are unwelcome but not unmanageable because they can be passed through either to customers or, at least partially, to health plan policyholders.
And for some governmental units, the expected costs represent a small percentage of overall spending. Lawrence officials, for example, estimate the new Obamacare fees will cost the city $137,200 in 2014, which could be considerably less than the potential costs of complying with a new conceal-carry firearm law passed earlier this year by state lawmakers.
Rural school districts
But the new health reform rules are particularly challenging for rural school districts and special education cooperatives, where officials say they have little or no place to turn for additional money, especially since state school aid has been held flat or reduced and more often than not the so-called “local option” school budget authority already has been maxed out.
“A lot of the districts and co-ops are looking at various options, including the option of getting out of offering health insurance and acknowledging that the most economical step for them is to pay the penalty and have their employees go to the exchange and get what's available through the marketplace. But a lot have not made that decision yet,” said David Shriver, assistant executive director for insurance services at the Kansas Association of School Boards.
The situation at the Phillipsburg special education cooperative offers a stark example of the complications many Kansas schools are facing, Shriver said.
The interlocal co-op is funded by 11 participating school districts that together cover an area of about 4,500 square miles spanning eight rural counties slightly west of the geographic center of the conterminous United States. It is square in the heart of the heartland. The districts collectively serve about 3,700 students, of which about 670 are in the special education program.
Hipp said NCKSEC Interlocal 636 has about 85 “certified” employees (mostly teachers) but also employs about twice that many people as “non-certified” teacher assistants or “paras” and other support staff.
Those workers, earning close to minimum wage, also are offered health benefits by the co-op. But about 100 of them don’t take it because it is too costly for them. The imbalance between their wages and their health insurance costs is so pronounced, Hipp said, that some of the para-educators who use the co-op’s health plan end up writing checks to the co-op two or three times a year just to cover their share of the benefits.
Under the health reform law, Hipp said, the interlocal must offer health coverage that meets the federal standard of affordability or pay a penalty for each employee that gets insurance through the subsidized federal exchange. The exchange — sometimes called a marketplace — is scheduled to be in operation by Oct. 1, with the coverage effective for policyholders beginning Jan. 1, 2014.
Here’s the dilemma for the co-op and similar organizations: On one hand, they can’t afford to pay their “non-certified” workers enough to make premium costs an affordable percentage of their incomes. But nor can the organizations afford to maintain a health plan and pay the annual penalties that must be paid by employers that have workers who opt for coverage through the insurance exchange.
Medicaid services for the disabled in Kansas have been undergoing dramatic changes in the past 18 months and in response many smaller providers of so-called “payroll agent” or “financial management services” for disabled persons who prefer to hire their own care attendants are either changing their business models or simply going out of business.
Some in the business predict major consolidations. Instead of dozens of small firms dotting the landscape, they foresee perhaps four or five large ones.
“There will just be less options for people. More consolidation. The bigger you are, the more likely you are to make a profit on FMS (financial management services),” said Scott Criqui, executive director of Trinity In-Home Care in Lawrence.
Trinity has been in business since 1976. But effective this month, it no longer will provide the administrative services it has offered clients who prefer to “self-direct” their personal care attendants.
Criqui said the nonprofit agency’s decision to stop providing the services was the result of state policy and reimbursement changes that began in November 2011.
“The reimbursement level for FMS is so low we're no longer going to be providing that service,” Criqui said.
For almost 20 years, disabled Kansans who rely on Medicaid for services that allow them to live at home and avoid having to move to a nursing home have had the choice of hiring their own attendants, which is called “self-directed care,” or using those provided by an agency – “agency-directed care.”
'Taken apart piece by piece'
Because personal care workers often provide a number of intimate needs such as helping with bathing, grooming and toileting, many disabled persons or their families have preferred the self-directed option instead of relying upon a person sent by an agency.
But to do that, they need the help of a “payroll agent” to process the timesheets and payments for the personal care attendant.
Now, it seems, many of the state’s 62 payroll agents are shutting their doors or concentrating on other types of services.
Doug Gerdel runs Life Patterns, a Topeka-based agency that serves about 400 self-direct customers in the eastern half of the state,
Historically, Gerdel said, Kansas had “always been way ahead of other states in terms of in-home supports and we were one of the very first states – back in the 1980s – to offer self-directed care.”
But that’s been changing as a result of the new policies.
“People can still self-direct,” he said. “But here in the last 18 months, you can see how that’s being taken apart, piece by piece.”
State officials said despite the changes they think there are enough payroll agent businesses to serve the state’s disabled.
“We currently have more than 60 FMS (Financial Management Service) providers in Kansas, and believe that represents an ample number of choices for consumers,” said Angela de Rocha of the Kansas Department for Aging and Disability Services. “The number of FMS providers fluctuates a bit every month. If there is an apparent consolidation, we are not seeing it yet. We would not be surprised to see some consolidation, but do not at this time anticipate anything too drastic. KDADS has no set optimal number of FMS providers.”
Some agencies, like Trinity in Lawrence, will continue to provide other services. But the agency has already notified more than 90 clients that it no longer will provide payroll agent services.
“It meant I had to quickly find a new payroll agent for my children,” said Shannon Graham, a Lawrence mother who adopted four significantly disabled children and relies on between eight and 10 personal care attendants and nurses to assist her with them. “I think it’s tough on everybody. The people who work and support my children in my home have to be rehired through a different agency.”
Graham said she would now rely on an agency in Olathe, Helpers Inc., for financial services.
KDADS officials said they had “seen no reports on the number of (Medicaid) waiver participants who are shifting agencies in order to continue to self-direct their services.”
'Change, change, change'
Anne Cousin is chief executive at Helpers Inc., which has more than 650 payroll-agent customers across the state. It is one of the larger operators.
“We intend to stay in business,” she said. “But we’re having to work harder than we’ve ever had to work just to stay on top of all the changes that are going on. Everything is change, change, change.”
Kansas insurance companies are preparing to sell a range of health plans on a new, online exchange being created by the federal government in an effort to make coverage more available to the thousands of people who have struggled to obtain it.
The Affordable Care Act, often called “Obamacare,” requires the new health insurance marketplaces to be up and running in every state by October, with the coverage sold through them effective on Jan. 1. But large numbers of Americans who stand to benefit most from the exchanges still know little to nothing about the law or how it will affect them, according to a recent poll by the Kaiser Family Foundation.
Anyone will be able to use the online marketplaces to purchase health coverage, but they are being created mostly to make private coverage more affordable for the uninsured and individual policies more widely available to those who don’t have access to group coverage through an employer.
“It’s going to create new opportunities for people who don’t have any insurance at all,” said Andy Corbin, chief executive of Blue Cross Blue Shield of Kansas, the state’s largest private health insurer. “And for those who don’t make much money, it may save them some dollars.”
Corbin said that plans offered on the exchange will “probably be more expensive” than the individual and small-group policies the company now sells. But he said in many cases the amount that consumers actually pay would be lower because of federal subsidies.
The exchange, or marketplace, also will give small businesses — those with fewer than 50 employees — new options. Rather than purchasing group insurance, they will be able to select a plan on the exchange and allow their workers to purchase individual policies. The businesses will have the option of helping their employees pay for the coverage, or not.
At least three insurance companies will sell multiple plans on the Kansas exchange, which will be operated by the federal government because Gov. Sam Brownback, a Republican opponent of the health reform law, declined to establish a state-run exchange. The companies are Blue Cross Blue Shield of Kansas, Coventry Health Care of Kansas and Blue Cross Blue Shield of Kansas City, which does business in two Kansas counties, Johnson and Wyandotte.
Subsidies to blunt higher premiums
Ron Rowe, a vice president for BCBS of Kansas City, predicted the cost of premiums for new, non-group policies would trend higher.
“Some people’s rates are going to go down and some are going to go up, but in aggregate it’s going to be about a 30 to 35 percent increase for that entire block of business,” he said.
But those increased costs could be mitigated for many. People who already have individual policies can keep them. And those who qualify for federal subsidies could end up paying less for more expensive and more complete coverage.
“Many people who are going to see big, high rate increases are going to qualify for a subsidy,” Rowe said. “And the amount that they’re going to pay out-of-pocket, net with the subsidy next year, will be less than they’re paying today even if the premium is significantly higher.”
For example, a person with annual earnings equal to 150 percent of the federal poverty level — $17,235 — would pay about $460 a year for a $5,000 policy, according to a cost-estimating tool developed by the Kansas Insurance Department. Federal tax credits paid directly to the insurance company would cover the remaining $4,540.
The credits, available only through the exchange, will be calculated on a sliding scale up to 400 percent of federal poverty guidelines, or annual earnings of $45,960 for an individual. But at that top level, the subsidy would amount to only about $630 leaving the consumer responsible for the remaining $4,370.
Despite the likelihood that many consumers purchasing through the exchange could pay less, both Corbin and Rowe said they anticipated a backlash from those forced to pay more.
“We’re trying to get out in front of the negative that’s going to come,” Corbin said.
To do that, he said, the company planned to do as much as it could to educate consumers about the exchange, the subsidies available and why some coverage would cost more.
Higher risks mean higher costs
Premiums are expected to rise because the reform law prohibits insurance companies from continuing practices they have historically used to reduce their risks. Those practices include denying or limiting coverage for high-cost individuals or capping their benefits. Going forward, the companies must sell policies to anyone regardless how sick they might be.
Kansas Insurance Commissioner Sandy Praeger, a Republican who has bucked the party line in supporting the law, said the old system often denied affordable coverage to people who needed it most.
“If you had any kind of pre-existing condition, you probably couldn’t buy (insurance) at all,” Praeger said. “You could be denied coverage because of allergies.”
LAWRENCE—Every day a small army of Kansans — officials estimate there are about 16,000 of them — are at work helping some of the state’s neediest cope with the demands of daily life so that they can remain in their own homes rather than nursing homes or state institutions.
The personal care attendants or PCAs, as they are called, do all sorts of things to help: They clean house, fix meals, line out doses of medications, change adult or infant diapers, scour feeding tubes, lift people on and off toilets and in and out of beds, bathtubs and wheelchairs. They advance the pieces on a board game so a child can play with a younger brother. They let the dog out. Sometimes they are small but tough women presented impromptu tasks that would intimidate others, such as calming a large, shouting man made erratic by a brain injury.
They are people like Cydney Bunner, a University of Kansas graduate student who helps a Lawrence family that has four significantly disabled children.
Or Sally Fronsman-Cecil, one of two personal care attendants for an 85-year-old Topeka woman who is diabetic, had a lung removed and is beginning to show signs of dementia but is still in her own home.
Or Fred Miller, a grown-up farm kid, who does the heavy lifting for a young woman robbed of self- locomotion by muscular dystrophy and a litany of accompanying ailments.
They usually are paid between $9 and $10 an hour, generally without benefits such as health insurance, vacation or paid time off to deal with their own illnesses or problems. Collectively, they care for about 20,000 Kansas Medicaid beneficiaries any given month.
Some are employed by agencies, others are hired directly by the people or families they help. Either way, it is Medicaid that pays for their labors.
“Without the personal care attendants and the nurses in my house, I would not be able to have the children that I have,” said Shannon Graham, a Lawrence woman who became a foster mother about 15 years ago and then ended up adopting five of the children in her care. Four of the five are seriously disabled. “It can be very intimate support that is provided. They become a part of your family at that level.”
‘Not even considered providers’
Graham said any given week she has between eight and 10 care attendants and nurses in her home helping with the children. She hires and trains most of them herself, she said, placing ads at the University of Kansas to be seen by prospective nursing students.
One of Graham’s sons, six-year-old Max, relies on a wheelchair. He is developmentally disabled and prone to serious epileptic seizures.
Max requires “a special diet because of his horrible epilepsy,” Graham said.
“He has a nurse with him all the time at school,” she said. “These people (the care attendants) have to be trained to learn to look at him and know when he might need oxygen. If he has a seizure, there's a protocol they need to follow and these people are getting paid 9 to 10 bucks an hour.”
Because they mostly help people in their homes, the work of the personal care attendant is largely unseen by the public and they often are overlooked by policymakers. Many, if not most, are exempt from wage-and-hour laws.
Lawrence call center expected to add positions to handle insurance exchange calls.
Four states that have snubbed the federal health law by defaulting to the federal government to build new online insurance marketplaces and not agreeing to expand Medicaid are getting new jobs at call centers that will help consumers understand their new coverage options this fall. Kansas is one of the four states.
Up to 9,000 jobs are expected to be created at call centers to support the new federally run marketplaces. A U.S. Department of Health and Human Services spokeswoman said some of them will be added to existing Medicare call centers in Phoenix, Chester, Va., Lawrence, Kan., and Tampa, Fla. — all states with Republican leaders who oppose the law.
A fifth center in Coralville, Iowa and a sixth in Corbin, Ky., will also be expanded, she said. Plans are still being finalized for other locations, she said.
Of those states, only Kentucky is setting up its own online insurance marketplace that will help people shop for individual or small employer coverage. Iowa, will run its exchange in partnership with the federal government. The other states are relying entirely on the federal government.
Of the six states getting call centers, only Kentucky has committed to expanding Medicaid in 2014, even though governors in Florida and Arizona say they support it. So far, 22 states have agreed to expand Medicaid.
The jobs are through Vangent, a General Dynamics Information Technology subsidiary, which was awarded a $530 million one-year contract by the federal government to set up call centers to answer inquiries related to the insurance marketplaces in 34 states where they will be run in whole or part by the federal government.
The government estimates that next October, when the marketplaces go live, the call centers will be open seven days of the week, 24 hours a day, handling 6.1 million phone calls and 23,000 e-mails. The contract could be renewed for up to nine more years, making it potentially worth more than $5 billion.
States running their own marketplaces will have their own call centers.
The marketplaces are expected to expand health coverage to about 27 million people by 2016. Under the federal contract awarded to Fairfax, Va.-based Vangent, the company will also field inquiries about Medicare, Medicare Advantage and “other relevant programs,” the award announcement stated.
Advocates for the developmentally disabled held a Statehouse press conference today to praise Gov. Sam Brownback's plan to reduce by 600 the number of disabled Kansans awaiting home- and community-based Medicaid services.
"We think this is a great move by the governor," said Tim Wood, campaign manager for End the Wait, a group pushing for elimination of the waiting lists. "This is a good step in the right direction."
Wood and fellow advocates also urged the Legislature to consider developing a plan to fully eliminate the waiting lists, which have grown over the past decade to include more than 5,000 people with physical or developmental disabilities. About another 1,200 people with developmental disabilities are receiving some of the services but waiting for more.
The governor last week released a budget amendment asking the Legislature to spend an additional $18.5 million to reduce the waiting lists. The recommendation came after state budget forecasters concluded that state spending on Medicaid services would be about $98 million less than previously expected for the fiscal year that ends June 30, including about $37.6 million from the State General Fund.
The governor characterized the reduced costs as "dividends" from the enactment of KanCare, the initiative he launched Jan. 1 that expanded managed care in the state Medicaid system. State budget analysts attributed much of the foregone spending to fewer people receiving Medicaid services. When federal officials approved the administration's KanCare plan, one of the "special terms" of the agreement was that if money were saved, some of it would be used to reduce the waiting lists.
Wood said he and other advocates also would urge lawmakers to aim for equal reductions in the lists for the physically disabled and the developmentally disabled. The governor proposed that the money be split evenly between the two waiting lists but because the cost of caring for the developmentally disabled is higher on average, fewer people could be served.
Wood said ideally that 300 people would come off each the two lists rather than 400 off the physically disabled list and 200 off the developmental disability list.
"While we appreciate the need to bring all people off the waiting lists," he said, "we want the Legislatuare to consider a fair and equitable way to divvy up the dividends."
In related news, spokesmen for Interhab, a group that represents most of the state's Community Developmental Disability Organizations, said more than 1,000 people had signed up to attend a rally scheduled for Wednesday at the Statehouse to urge legislators to exclude long-term DD supports from inclusion in KanCare.
The following video was produced to present to Kansas legislators by the advocacy group End The Wait, which is funded by the Kansas Council on Developmental Disabilities.
People involved with Medicaid services for children say they are hopeful the state’s new KanCare program will someday lead to improved services and health outcomes.
But for now, they report dealing with some of the same problems and frustrations others in the program, which also serves the poor elderly and disabled, have experienced since its launch on Jan. 1: Billing problems, payment delays, concerns about patient access to care and increased administrative complexity.
“There are a lot of bumps in the road; we'll put it that way,” said Dr. Melinda Miner, a Hays Dentist who along with her husband, Dr. Daniel Miner, is one of the leading Medicaid dental providers in her part of the state.
Miner said her clinic just recently began receiving payments for services earlier this year from the KanCare managed care companies and that other dental providers she knows have had the same problem.
“We still have a lot of outstanding claims,” she said. “We never had problems like this when the state ran the program (using two managed care companies). That was the best thing about HealthWave, claims got paid in a timely manner. You didn’t have to worry about them. I think they have that under control now, or at least they’re working hard on it.”
Other Medicaid providers for children also described problems when interviewed by KHI News Service.
“From a provider perspective, it’s been kind of frustrating,” said Dr. Dennis Cooley, a Topeka pediatrician who sees a large number of Medicaid patients, “mostly from dealing with three, brand new MCOs (managed care companies) and each one has their own set of rules.”
'A lot of difficulties'
Cooley, like others dealing with the new system, said “we’ve had a lot of difficulties with prior authorizations,” which are the approvals for payment required from the state’s KanCare contractors before services can be delivered to a patient. “We’ve had difficulty, I think, in getting our patients some of the services, especially like with pharmacy and what meds (the MCOs) are covering. I know at least in our practice it’s been very frustrating and that’s what I’ve heard in talking with other providers, too.”
Cooley said his practice “had good rapport” working with the state’s prior HealthWave managed care companies and that “time would tell,” if the same sort of relationships would develop with the new KanCare contractors: Amerigroup, UnitedHealthcare and Sunflower State Health Plan a subsidiary of Centene.
And here’s an assessment of KanCare’s progress from Tribune, a small town near the Colorado border.
“It’s going OK, we’re just butting up against some billing issues,” said Bonnie Mote, who handles the billing for Greeley County Health Services, a rural health clinic once directed by Dr. Robert Moser, currently secretary of the Kansas Department of Health and Environment, the state’s lead Medicaid agency.
Mote said she thought services for patients had been unaffected by KanCare and that the claims and billing problems would soon be sorted out.
“Dr. Moser contacted us and said they (KDHE) would be contacting the MCOs,” she said.
KanCare moved virtually all the state’s 380,000 Medicaid enrollees into managed care plans run by for-profit insurance companies. But even before the program makeover, the large majority of beneficiaries — more than 280,000 — were children covered by what was then known as HealthWave.
Push is again coming to shove in the struggle over whether the long-term care and support services received by Kansans with developmental disabilities will become part of KanCare or remain outside the control of the private companies hired by the state to manage the Medicaid program.
Advocates pushing for a permanent “carve out” of developmental disability services have circled May 8 on their calendars. That’s the day that the Kansas Legislature is scheduled to return to Topeka to wrap up its 2013 session.
“When you show up in numbers, it makes a difference in the legislative process,” said advocate Tom Laing, speaking last week to approximately 175 parents and advocates at a meeting sponsored by Johnson County Developmental Services.
“A lot of times when politicians do the wrong thing it’s because they haven’t heard from the folks who are the most impacted. If they don’t hear from you, we can’t succeed,” said Laing, executive director of Interhab, an association that represents most of the state's Community Developmental Disability Organizations.
Laing and other advocates said they are hoping that thousands of Kansans with developmental disabilities would turn out with their parents and guardians for a rally on the south steps of the Statehouse and to meet individually with legislators to make their case.
“I’m not a guy who believes in pitch forks and torches. We need to be persuasive, not abrasive,” Laing said.
'Carve in' date approaching
Medical services for the developmentally disabled already are part of KanCare, the reform initiative launched on Jan. 1 by Gov. Sam Brownback. It moved virtually all of the state’s 380,000 Medicaid beneficiaries into managed care plans run by three insurance companies: Amerigroup, United Healthcare and Sunflower State Health Plan, a subsidiary of Centene.
But yielding to pressure from advocates and service providers, the governor and legislators agreed last year to delay the inclusion of long-term, DD support services for a year — until Jan. 1, 2014. With the “carve in” date approaching, advocates are pressing their case again.
“We have to keep these services out of the hands of the profiteers,” said Bridget Murphy, director of the Downs Syndrome Guild of Greater Kansas City.
'Misinformation' fueling concerns
Murphy’s concern that the for-profit managed care companies will disrupt services now generally provided by a network of community-based, non-profit organizations is shared by many parents and advocates.
That frustrates Shawn Sullivan, the secretary of the Kansas Department of Aging and Disability Services, who has spent more than a year meeting with stakeholders to convince them they have nothing to fear from the new managed-care system.
This GIF animation from the Centers for Disease Control and Prevention shows the country as a whole growing much fatter between 1985 and 2010.
Fewer than 10 percent of Kansans were obese in 1985. A report released Thursday indicates that 29.6 percent of Kansans were obese in 2011.
The colors on the CDC map indicate the percentage of people medically designated as obese, or with a Body Mass Index of 30 or greater.
However, BMI is somewhat of an imperfect measurement of obesity, said Kansas Health Institute Senior Analyst Barb LaClair.
"BMI is calculated using weight and height. But muscle tissue is more dense, and so it weighs more than fat. So people who are really fit and have a lot of muscle tend to weigh more for their height, but not because they're obese," LaClair said.
In other people — particularly older people who have lost muscle — BMI may underestimate obesity, according to the National Heart, Lung, and Blood Institute.
Nevertheless, CDC officials say BMI is generally a reliable way of indicating whether a person’s body fat may eventually lead to other health problems, such as heart disease, diabetes, cancer and hypertension.
Advocates pushing Kansas officials to expand Medicaid acknowledge it is unlikely they will achieve their goal this year.
But they said they remain hopeful they can convince Gov. Sam Brownback and legislators next year to make more Kansans eligible for the program.
“If it’s not going to happen the first year, we’ll continue to build grassroots support. We’re not giving up,” said Anna Lambertson, director of the Kansas Health Consumer Coalition, one of the groups pushing for expansion.
Medicaid, known in Kansas as KanCare, currently provides medical and long-term living assistance services for about 380,000 poor, disabled and elderly Kansans. Expansion could increase enrollment in the program by as many as 240,000, according to various projections.
The federal Affordable Care Act initially required states to expand Medicaid eligibility. However, the U.S. Supreme Court decision that upheld the law made expansion optional for states.
Expansion would have a bigger impact in Kansas than in many other states. That’s because the state’s current eligibility criteria exclude all but the poorest adults. Only those with children and incomes less than 32 percent of the federal poverty level — about $6,000 a year for a family of four — can qualify. Implementing expansion would mean that adults in that same family of four could make more than $31,000 a year and qualify.
The Brownback administration has estimated that expanding eligibility for the $3.2 billion program would cost the state an additional $600 million over 10 years.
Door still open
Whenever asked about expansion, Brownback says things that suggest he’s more likely to say “no” than “yes” to it. But advocates said they remain encouraged by the fact he hasn’t rejected the idea.
“If he’s really looking at the options with an open mind — as he himself has said he’s doing — then I see him taking his time (to decide) as beneficial,” Lambertson said. “I’d rather that he take his time than just say ‘no’.”
Last week, Brownback again expressed doubts that the federal government could afford to keep its promise to cover all the costs of expansion for the first three years and no less than 90 percent thereafter. Despite his misgivings, he said, he continues to have “active conversations” with expansion advocates and legislators on the topic.
“It’s in the legislative process,” Brownback said. “Expansion would have to be addressed by the Legislature. They would have to budget it.”
Brownback’s requirement that legislators budget for it before he would sign off on it has advocates convinced a decision won’t be made this year.
Members of the House-Senate conference committee negotiating a final version of the fiscal 2014-15 budgets are scheduled to return to the bargaining table early next month when the Legislature returns to Topeka for what leaders hope will be a brief wrap-up session.
The first 90 days of KanCare have passed, which means the transition period during which the state's 380,000 Medicaid beneficiaries could switch managed-care health plans this year is over.
That is important — for among other reasons — because many KanCare enrollees may find themselves in situations where the medical providers they are accustomed to using are not in the network of the KanCare plan to which they were assigned or chose themselves before the changeover period ended April 4.
And as the 90th day was marked last week, many Medicaid providers continued to report persistent problems with the program that was rolled out Jan. 1 by the administration of Gov. Sam Brownback.
'Number of issues'
"We still have a number of issues that pharmacists have to deal with," said Michael Larkin, executive secretary of the Kansas Pharmacists Association. "In the big picture, our number one concern is assuring that the managed care organizations adhere to the contracts signed (with the state) back in June."
Larkin said the contracts called for the KanCare companies to use a "transparent" process for determining the reimbursement rates for pharmacy services. In the association's view, he said, those contract provisions have been ignored by the KanCare companies "across the board."
"And also the managed care organizations when they do change their pricing are supposed to notify us, let it be known to everyone that the pricing has changed. I don't know that they're doing that either," Larkin said.
He said a meeting was held last month with KanCare company representatives to try to resolve the concerns but that the problems continue apparently because "the wrong people were in the room to discuss that."
Larkin said he was trying to set up another meeting that also would include state officials.
Association members also are reporting reduced or delayed payments from the KanCare companies for durable medical equipment.
"They're having trouble getting proper reimbursement and knowing, if in fact, they will be reimbursed before the equipment goes out the door," Larkin said.
Administration officials acknowledged some ongoing problems but said on whole they are pleased with the program's progress.
"It's been very workmanlike," Lt. Gov. Jeff Colyer said of the transition.
He also repeated what administration officials have said since the first month of KanCare: "There haven't been as many bumps in the road as we expected. Everybody's been very committed to working with people who are having issues."
Larkin said from the pharmacists' perspective the problems have been "something in between a bump in the road and grave concern."
"We're hopeful things will turn out for us. So far, it hasn't happened," Larkin said.
With the filing deadline approaching, the nation’s largest tax preparation company is letting its customers know how they are likely to be affected by the Affordable Care Act.
“After the ACA was upheld by the Supreme Court in 2011, we did some focus groups and some surveys to try and measure the public’s understanding of what all is in the ACA,” said Meg Sutton, senior advisor for tax and health care services at H&R Block. “It became pretty clear that there needed to be a process for educating our clients.”
Sutton called the 2010 federal health reform law the “biggest tax-code change in the past 20 years.”
The company’s tax preparers, she said, have been calling their customers’ attention to the ACA’s penalties for not having health insurance and to the subsidies that will be available to low- and modest-income families.
The information also is available on an H&R Block website.
“Client reaction has been very positive,” Sutton said.
The company’s surveys, she said, had found that 77 percent of its clientele didn’t realize their 2013 tax returns would be used to determine their eligibility for health insurance subsidies and that 44 percent of those between ages 18 and 34 were unaware of the penalties for being uninsured.
Sutton said the company’s tax preparers do not tell their customers to buy - or not to buy – health insurance. Instead, she said, customers are “informed of their options” based on the information in their 2013 tax returns.
The ACA’s mandate that almost all Americans either have health insurance or pay a penalty takes effect Jan. 1, 2014.
Marvin Lawton has been a tax preparer at the H&R Block office in Topeka for the past eight years.
“I’ve found there to be quite a cross section in the way people react – all the way from being OK with it to being dismayed by it,” he said. “Some are OK with it because they already have insurance and won’t be affected by it, some are bewildered over how they’re going to afford it and some wonder why they have to pay a penalty if everybody in their family is healthy."
Most of his customers with little or no health insurance have seemed pleased to hear about the subsidies, he said.
“I’ve had a lot of people who used to have insurance through their job but ended up getting laid off in the past year,” he said. “They know how expensive health insurance is. So when I tell them about penalties, they say ‘But I can’t afford it.’ Then, when I tell them about the subsidies and how they’ll be able to buy it through the exchange and be part of a larger pool, they’re OK with it. They say they’re OK with it if it’s affordable. And I say that’s the intent, that’s why it’s called the Affordable Care Act.”
H&R Block customers have the option of signing up for email alerts on changes in the new health reform law.
Sutton said, H&R Block appears to be the only national tax preparation firm helping its customers predict the law’s effect on their 2014 taxes.
Surveys have shown that about 60 percent of the nation’s taxpayers use tax preparation companies. H&R Block accounts for almost 20 percent of the tax-preparation market.
Kansas Health Consumer Coalition Executive Director Anna Lambertson said she welcomed the company’s initiative.
“I think it’s great,” Lambertson said. “I give them high marks.”
The coalition, she said, has been looking for ways to launch a similar informational campaign in Kansas.
“We can’t do it alone,” she said. “And H&R Block can’t do it alone. It’s going to take everybody getting involved.”
Sheldon Weisgrau, a spokesman for the Health Reform Resource Project, also praised the company.
“I assume they’re hoping this will lead to more people coming to them to have their taxes done,” he said. “But that’s fine. Anytime you’ve got someone providing accurate information it’s a positive.
Weisgrau said federal officials have announced plans for launching a major outreach campaign in June.
“They don’t want to start too early, which makes sense,” he said. “The exchange won’t be up and running until October.”
Mary McBain, chief executive of the Kansas Society of Certified Public Accountants CEO said the H&R Block initiative had not gone unnoticed.
“The major accounting firms have definitely been ramping up for this,” she said. “Some of the bigger firms have hired people just to work on ACA – that’s all they do.”
MacBain said her organization was committed to providing its members with accurate information about the law.
“All of us, I think, need to take a deep breath and not get caught up in all the emotion that’s comes with health care reform,” she said. “We need to be informed because, frankly, there’s a lot of misinformation out there.”
→ Find more information on health insurance exchanges and other health reform topics at khi.org/healthreform.
In response to news reports they said were based on a "false premise," state health officials today said they have no intention of quarantining people infected with or exposed to HIV.
“It is not and never was the state’s intent to seek the authority for isolation or quarantine of persons related to HIV,” said Charlie Hunt, epidemiologist at the Kansas Department of Health and Environment.
The Kansas Legislature has been advancing Substitute House Bill 2183, which would give KDHE authority to order certain health care workers to be tested for infectious diseases — such as HIV or tuberculosis — to prevent them being spread.
Workers covered by the bill include those who:
"provide medical or nursing services, clinical or forensic laboratory services, emergency medical services and firefighting, law enforcement and correctional services, or who provide any other service or are in any other employment where the individual may encounter occupational exposure to blood and other potentially infectious materials."
Existing law only authorizes KDHE to designate which diseases are infectious and to adopt regulations for the isolation and quarantine of persons exposed to the diseases to prevent their spread. The agency supports the bill, which currently is subject to negotiations in a House-Senate conference committee.
Hunt said some media outlets had mischaracterized the bill in their reports, causing public concern.
"Much of the recent media coverage has been based on the false premise that, if enacted, the bill would allow for isolation of persons infected with or quarantine of persons exposed to HIV,” he said.
That isn't legal under current law and the proposed new law wouldn't change that.
“The law requires isolation and quarantine be based on what is reasonable and medically necessary and neither of those thresholds are met with respect to HIV,” Hunt said.
Confusion over the bill was fanned when a TV station in Wichita earlier this week broadcast an interview with an AIDS activist who said he feared it might allow a health official to wrongfully quarantine an AIDS victim. A couple of national websites picked up on that story and then it spread rapidly via Twitter and Facebook.
Sen. Laura Kelly, a Topeka Democrat, was among those voting against the bill when the Senate passed it last week, 29-11.
She said many constituents had expressed concern to her over the bill.
"I think they have a right to be concerned," Kelly said.
She said she thought the concern stemmed from ambiguity in the bill, which she said had since been addressed in a conference committee meeting Wednesday.
"We inserted 'medically necessary and reasonable'," Kelly said. "That makes me a lot more comfortable."
She said she had discussed the changes with Hunt and a KDHE lawyer and that the new language settled her concerns with the bill.
"I asked them very specifically 'Is it ever medically necessary or reasonable to quarantine or isolate somebody with HIV/AIDS?' And they said 'No.'"
The conference committee is slated to meet sometime Monday to vote on the new language in the bill.
The Senate has tentatively approved a bill that could lead to some school districts holding back first graders who fail a reading test.
The measure was based on Gov. Sam Brownback’s proposal for improving fourth grade reading scores by holding back third graders known to be having trouble reading.
“We need to be getting to these kids as early as we can,” said Sen. Laura Kelly, a Topeka Democrat, who proposed changing the focus of Senate Substitute for House Bill 2140 from third graders to first graders.
Kelly’s amendment was endorsed by Sen. Steve Abrams, an Arkansas City Republican and chair of the Senate Education Committee.
“It’s fairly well known that through the third grade children are learning to read,” he said. “After the third grade, they’re reading to learn.”
Abrams said he considered Kelly’s amendment to be “friendly.”
The Senate endorsed the bill on a voice vote shortly before 8 p.m. Tuesday. A formal final action vote is set for Wednesday morning.
Abrams said an earlier version of the bill had stalled in the education committee after several members argued that it constituted a mandate and was likely to do more harm than good.
Those concerns were resolved, he said, by adoption of a number of amendments in the committee and during the floor debate aimed at exempting students in special education or English-as-a-Second-Language classes, allowing students to take the test more than once, limiting the mandate to school districts with below-average reading scores, and giving parents the final say in whether their children were promoted.
“The concern that what was initially proposed did not include parental involvement ended up being resolved in this bill,” Kelly said.
The amended bill also would allow teachers to declare whether students who fail the test should be allowed to advance.
It wasn't immediately clear how many first graders might be affected by the bill or what the cost might be for school districts. Neither question was raised during the debate.
Child advocates had testified against the initial bill, arguing that state resources would be better spent on early childhood development programs, many of which have long waiting lists.
Shannon Cotsoradis, chief executive for the advocacy group Kansas Action for Children, welcomed the changes to the bill.
“Tonight’s floor debate in the Senate underscores the commitment to early intervention and to investments in early learning programs as a path to literacy,” she said. “The amendments will also provide the flexibility to act in the best interests of individual students rather than mandating a one-size-fits-all approach.”
The bill calls for spending $10 million — $5 million a year for two years — on a grant program aimed at helping children learn to read.
It also would set aside $1 million a year for two years to reward school districts with the most improved reading scores.
If the bill passes on final action, as expected, it would be sent to the House, where it’s likely to be referred to a conference committee.
Related stories on khi.org
→ Brownback reading initiative questioned by education experts
→ Governor's office restates support for reading initiative
Susan Wagle, already distinct in history as the first woman elected president of the Kansas Senate, said there are other things for which she would prefer to be remembered:
“A fiscal conservative, a social conservative, a mom, a businesswoman and a schoolteacher . . . that’s pretty diverse,” she said.
This is her 23rd year in the Legislature — 10 in the House, 13 in the Senate.
Her tenure has been punctuated by causes she took on when broader interest among legislators was not always apparent and which brought her statewide, sometimes national, attention.
“I’m a second-born of six children — two boys and four girls - and you know how second-borns are,” she said. “I was a challenge for my parents and I can be a challenge up here (at the Statehouse) if it’s an issue I care about.”
The 59-year-old Wichita resident was at the forefront of a conservative Republican takeover of the Senate in the November 2012 general elections.
She was elected the chamber’s leader in December and in January presided over a major rules change that barred any floor amendments that would add costs to spending bills. That so-called ‘pay-go’ provision, championed by conservative Republicans, was adopted 28-11, mimicking one already in force in the House.
‘Dancing not dating’
Despite that and other changes, she is regarded by some as “old school.”
“In many respects, I believe Susan is kind of old school in terms of her appreciation of the political process and the exchange of ideas,” said Senate Minority Leader Anthony Hensley, a Topeka Democrat.
ln 2002, he said, she worked with Democrats on a Senate redistricting map that was adopted despite opposition from Republican moderates, then the majority in the GOP caucus.
He also credited her with putting together a coalition of GOP conservatives and Democrats to break a 2007 budget deadlock.
“Just because she’s of a different political stripe doesn’t mean we can’t work with her,” Hensley said. “We’ve always had an understanding that we’re only dancing, we’re not dating.”
Health policy background
Wagle has had more experience with health policy issues than has been the norm for those who have risen to the Senate presidency.
From 2001 to 2007, she was chair of the chamber’s Health Care Strategies Committee. It was a period in which the Legislature was unusually active in its consideration of potentially far reaching state Medicaid and other health reforms.
She also had an unsuccessful run at statewide office before becoming president, which is a bit uncommon in that top legislative leaders often aren’t that well known to general voters outside their own districts.
In 2006, she ran for lieutenant governor on the ticket with GOP gubernatorial nominee Jim Barnett of Emporia, a physician and fellow senator who since has retired from politics. The pair was handily defeated in the general election by Democrat Kathleen Sebelius and her running mate Mark Parkinson.
In 2000, Wagle launched an investigation of how then- Kansas Attorney General Carla Stovall, a fellow Republican, had hired her former law firm to represent the state in the lawsuit that led to the master settlement agreement with the nation’s tobacco companies. Stovall’s former firm collected $27 million for its role. The state's ongoing share in the settlement has been earmarked mostly for children’s programs.
Three years later during debate on the Senate floor, Wagle accused a professor at the Kansas University School of Social Welfare of showing pornographic videos, condoning pedophilia, and using foul language in a popular class he taught on human sexuality. Her move to cut funding for the school was vetoed by Sebelius.
A subsequent university investigation and report on the allegations exonerated the professor.
In 2011, as chair of the Senate Commerce Committee, Wagle held several contentious hearings on allegations that the chief executive at the Kansas Bioscience Authority had mishandled or misrepresented the agency’s activities. The executive resigned and took a job out of state.
“You want her on your side,” said Tim Shallenburger, a former Kansas House speaker who now serves as Gov. Sam Brownback’s chief legislative liaison. “Not so much because she’s president of the Senate but because of the passion she brings to an issue. She’s very hard working.”
Wagle says her political energies are now focused on improving the economy.
“Clearly, the state of Kansas is in the midst of an economic downturn, followed by long-term stagnation that, I believe, has been caused by a lack of leadership at the federal level,” she said. “We’re at a turning point. If we don’t get control of federal spending, this country and this state will take a turn for the worse and the opportunities I had growing up will not be the same as those that my children will have.”
The best way to stimulate the state’s economy, she said, was “…through lower taxes, smaller government, and less regulation.”
She said she shares that view with Gov. Sam Brownback, a confidante for many years, and House Speaker Ray Merrick.
“We are unified on that goal, although we may have to take different paths to get there,” Wagle said.
Wagle, a former elementary school teacher, said her readiness to cut taxes dated to 1986 when a statewide reappraisal tripled the property taxes on some commercial property that she and her husband owned.
“Our taxes went from $5,000 a year to $15,000 a year,” she said. “I was shocked.”
Four years later, she ran for the House and won.
Wagle, who grew up in east Wichita, also is well known for her opposition to abortion.
“I didn’t start out pro-life,” she said. “I graduated from (Wichita) Southeast (High School) in 1972, which was about the time that Dr. (George) Tiller started his practice. I had friends — young girls — who saw the clinic as a form of birth control and who later suffered emotional consequences. But we were young and I didn’t think that much about it.”
Is the whirl of hospital revolving doors slowing?
Federal health officials are now reporting that the rate of preventable and costly hospital readmissions is down for the first time in more than five years, which meant about 70,000 fewer hospital returns nationally in 2012 for the Medicare program alone.
With a strong push from the federal health reform law, scores of medical and social service workers around Kansas — like thousands of their counterparts in other states — are working together on projects that officials say show promise for reducing avoidable readmissions.
If they succeed, hospitals could be spared some of the Affordable Care Act penalties they face in the form of reduced Medicare payments and federal health care spending could be trimmed $8.2 billion by 2019, if projections from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS) prove accurate.
Starting in October 2012, almost 30 of the 46 non-exempt Kansas hospitals were punished for relatively high readmission rates in the first year of the ACA program, according to information from CMS compiled by Kaiser Health News, a partner of KHI News Service.
Because of the potential financial sting attached, nobody wants to be on that penalty list when it’s redrawn for this year, especially since last year’s maximum penalty of a 1 percent reduction will grow to a maximum 2 percent and then 3 percent for 2014.
“Almost every hospital is looking at this, because they stand to gain or lose,” said Ken Mishler, chief executive of the Kansas Foundation for Medical Care, a Topeka-based, non-profit organization that is the federal government’s sole designated contractor in Kansas for improving health care quality. In federal parlance, the foundation is known as a Quality Improvement Organization or QIO.
Mishler’s group was directly involved with organizing projects in four locations - Hays, Topeka, Kansas City and Wichita – but there are others underway, too, including one by the Kansas Healthcare Collaborative, a 2008 creation of the Kansas Hospital Association and the Kansas Medical Society.
There is evidence the various efforts, some of which predate the ACA, may be working. The readmission rate in Kansas was already lower than the national average, but recent numbers show even that somewhat lower rate has dropped.
According to the Kansas Foundation for Medical Care there were 49.4 per 1,000 Medicare fee-for-service patients readmitted to Kansas hospitals within 30 days in 2011 versus 52.5 in 2010. That compares favorably to the national average of 56.8 per 1,000 in 2011 and 58.2 per 1,000 in 2010. Foundation officials say the ultimate goal is a 20 percent reduction.
The efforts to make that happen in Kansas vary place to place but among the things they have in common is the involvement of multiple types of medical and social service providers or agencies, not just hospitals.
The reason for that, experts say, is that one of the best ways to reduce readmissions is to make sure that patients get proper follow-up care or attention after they are discharged whether they leave the hospital to live alone at home - where they may receive limited assistance from a variety of outside sources - or a skilled nursing facility where they get more-or-less 24-hour attention.
‘A community problem’
“It’s not just a hospital problem. It’s a community problem and you have to get all the providers together. It’s not easy work. It’s hard work,” said Laura Sanchez, the project director for the Kansas Foundation for Medical Care.
A bill that would roll back a requirement that Kansas utility companies increase their use of renewable energy has been saved from the legislative bell.
The House failed last week to pass the bill — HB 2241 — as lawmakers worked to meet a mid-session deadline for moving legislation from one house to another. Instead, members voted 63-59 to send the measure back to committee.
Ordinarily, that would have ended consideration of the bill. However, House leaders quickly revived it by sending it to the Committee on Appropriations, where bills may remain alive until the end of the session.
The fact that the House leadership re-routed the bill indicated supporters were gearing up for another attempt to pass it.
Current law requires Kansas utilities to obtain 20 percent of their peak-demand power from renewable sources like wind and solar by 2020. The House bill would roll back that requirement to 15 percent, a benchmark state utilities have already all but met.
Opponents of the bill say passing it could send a negative signal to the wind energy industry strong enough to end a building boom that has created 13,000 jobs and pumped more than $7 billion into the Kansas economy since 2001.
“Why would we want to do that,” asked Rep. John Doll of Garden City. “It’s like stopping at the end of the race so to speak.”
Doll is one of several Republicans questioning the wisdom of rolling back regulations that supporters say have benefited the state economically while having no apparent impact on electric rates.
Opponents of the regulation point to studies by conservative think tanks that show renewable standards have contributed to rate increases in other states. But the fact they haven’t substantially increased rates in Kansas has weakened the case for the bill.
“It seems like that message isn’t true,” said Rep. Ronald Ryckman, Sr., a Republican from Meade.
The Kansas Corporation Commission tracks the impact of renewable standards on rates. In 2012, wind energy accounted for 0.72 cents of the average retail electric rate of 9.2 cents per kilowatt hour, according to the commission’s most recent report.
Despite that, influential national conservative organizations are pushing for passage of the roll-back bill. They include the American Legislative Exchange Council (ALEC) and American’s for Tax Reform, the organization headed by Grover Norquist.
In a letter sent last week to Kansas legislators, Norquist called renewable energy standards a “command and control policy” that forces utilities to utilize “more costly and less reliable” energy. He said while the roll-back bill was a good start, “Ultimately, it is imperative that lawmakers repeal the mandate all together.”
Kimi Narita, an energy fellow with the National Resources Defense Council, devoted her latest blog to the renewable battle in Kansas. In it, she cited “giant forces” behind the Kansas effort, which she calls “a nation-wide attack” on renewable standards that are on the books in 29 states and the District of Columbia.
“Kansas is one of the priority states on their list, and repealing the Kansas RPS represented a critical first step in their momentum building strategy,” Narta wrote.
More often than not, many of the groups pushing for a roll-back of the renewable standards are aligned with Republican Gov. Sam Brownback on issues. The renewable standards are an exception. Several legislators and lobbyists said the governor’s quietly stated concerns about weakening the standards led to the defeat last week of a Senate bill that would have given utilities more time to meet them. The bill — SB 82 — was defeated 27-13.
While acknowledging “bumps in the road,” state officials for several weeks have been saying that the launch of KanCare, the state’s new Medicaid program, has been going better than they expected.
But people who work at some of the clinics that specialize in treating poor and uninsured Kansans describe it differently. They say the transition, now entering its third month, has been an ordeal for them and that some of the problems are compromising patient care.
“I went through the tornado in Joplin (in May 2011) and survived,” said Lori Lowrey, chief revenue officer for the Community Health Clinic of Southeast Kansas. “I would equate the anxiety of KanCare with the anxiety I felt following that event. It’s just been an inferno everyday. When you walk through the door, you’re greeted by staff frustrated at every level...nurses, administrators, patients and then trying to communicate with the (KanCare companies) and their contractors, it’s just very taxing. I just don't feel like it’s been accurately portrayed by the people at the state level or the MCOS (managed care companies). It’s been a road full of potholes. It’s not been a few bumps.”
The clinic here serves about 29,000 people a year at its eight sites scattered across the corner of Kansas that generally ranks as the state’s poorest and least healthy. That makes is a key medical provider, particularly when it comes to primary care for the poor. About 35 percent of its patients are on Medicaid, according to clinic officials.
State and KanCare company officials acknowledge there have been problems at the safety net clinics and more so at some of the 16 that are designated as Federally Qualified Health Centers, which includes the Community Health Clinic of Southeast Kansas. The FQHCs together have more than 20 satellite clinics scattered across the state and collectively serve many thousands of the state’s poorer families.
A special meeting that included clinic directors, state officials and KanCare contractors was held privately two weeks ago in Topeka to discuss the situation.
An “issues log” of 86 problems submitted by the clinics to the Kansas Association for the Medically Underserved (KAMU), a group that represents the safety net clinics, was presented at the meeting.
Among the problems cited:
Delayed or stalled payments from the KanCare companies,
Poor communication and misinformation
Troubles getting clinic doctors and other providers included in the KanCare provider networks and patients properly assigned.
Difficulty getting treatments or medications approved for patients.
The list was similar to but longer than the problem tally submitted to state officials a week earlier by the Kansas Medical Society and the Kansas Medical Group Management Association along with a letter asking the state to extend the KanCare transition period to allow more time for smoothing things out.
Kari Bruffett, the director of the Division of Health Care Finance at the Kansas Department of Health and Environment, has been the point person for the administration of Gov. Sam Brownback on much of the KanCare implementation.
Bruffett said state officials determined from the meeting with clinic officials “that while there were some crosscutting issues, there were a lot of issues specific to the individual (clinics), so what we asked the managed care organizations to do with those (clinics) was to work with them individually and basically keep us posted.”
She said she had been assured that many of the problems raised at the meeting were being dealt with and that the chief executives of the KanCare companies have been responsive whenever concerns were brought to their attention.
One result of the meeting, according to some who attended, was an agreement by at least two of the KanCare companies to make “advance payments” to clinics that asked for them to help deal with their cash-flow problems.
“I know of at least one (KanCare MCO) that is in the process of sending out advance payments,” said Cathy Harding, executive director of KAMU, “and another said they would do the same thing.”
She said she expected the third company also would agree to advance or expedited payments.
But in a series of interviews late last week with the KHI News Service, clinic directors from across the state give KanCare what could at best be described as mixed reviews. And those unhappy with the way KanCare is rolling out said they had seen little or no improvement as a result of the meeting.
“In our opinion, it’s kind of going from bad to worse,” said Krista Postai, executive director of the Community Health Clinic of Southeast Kansas. “I have nurses now spending all day on the phone trying to get pre-approvals (for patient medications from the KanCare insurance companies or their subcontractors) and not getting them. A lot of my providers have been doing this for years and they never had anything this absurd on pre-authorizations. I understand that is meant to control costs…but this is costing us a fortune.”
One of the state’s largest assisted-living chains has curtailed its participation in the Kansas Medicaid program.
“Of our 18 facilities, 15 are no longer taking any new Medicaid clients,” said Denise German, senior vice president of Vintage Park, which is headquartered here.
The decision, German said, was driven by a 2012 reduction in Medicaid reimbursements and by concerns that payments would be cut more under KanCare. The three Vintage Park facilities that still accept Medicaid clients are in towns with no other facilities. The company’s local administrators there chose to continue so there would be local options for residents.
KanCare is the name for Gov. Sam Brownback’s Medicaid makeover initiative, which involved the hiring of three managed care companies to run day-to-day operations of the state’s $3.2 billion Medicaid program. The KanCare companies are Amerigroup, UnitedHealthcare and Sunflower State Health Plan, a subsidiary of Centene.
The companies took over Jan. 1.
Looking to cut costs
“These are for-profit companies. We know they’re going to be looking for ways to cut costs and since reimbursement is very minimal already, we’ve elected not to continue to participate in the program,” German said.
Vintage Park began changing its policy a few months after Brownback first announced his KanCare plan in November 2011. Its individual Kansas facilities began making the changes more or less at their own pace. The result has been a major reduction in the number of Medicaid residents. Before this year, German said, Vintage Park facilities in Kansas had been admitting about 100 Medicaid residents annually.
“A year ago, we probably had 250 Medicaid residents in 18 facilities,” she said. “Now, I’d say we’re down to about 120.”
The company, she said, has been doing “fine” without new Medicaid admissions.
Vintage Park won’t ask private-pay residents to leave if they deplete their life savings and end up on Medicaid, she said. But the 15 facilities no longer admit residents already on Medicaid.
Vintage Park is a for-profit company. Most of its facilities are in small and mid-size towns in the eastern third of the state. All 18 facilities passed state inspections the last two years with no deficiencies noted, which generally is taken as an indication of well-run operations.
Not identified as a problem
It’s not clear whether other companies are following Vintage Park’s lead. State officials said they were unaware of the company’s decision and hadn’t seen evidence of a problem.
“We have not heard that assisted living facilities are declining to admit residents who are on Medicaid,” said Angela de Rocha, a spokesperson for the Kansas Department for Aging and Disability Services.
“Assisted living facilities’ refusal to accept residents who are on Medicaid has not been identified as a problem at this point,” she said. “And it is in the financial interest of the (KanCare managed care companies) to keep their members in a community setting instead of admitting them to nursing homes.”
An assisted living facility is considered a community setting.
Others in the industry said they knew too well the pressures cited by Vintage Park officials.
“Our company continues to accept Medicaid,” said Steven Hatlestad, vice president of skilled nursing operations at Americare, another for-profit chain with operations in several states that has 11 nursing homes and six assisted living facilities in Kansas. “But I do not believe that what Vintage Park is doing makes it an outlier. I’m afraid we’ve reached a point where some companies — some really good companies — just can’t afford to do Medicaid anymore.”
Ray Vernon runs Wesley Towers, a large retirement community in Hutchinson that offers in-home care, independent living, congregate living, skilled nursing care, and assisted living. It is a subsidiary of the Kansas West Conference of the United Methodist Church.
Vernon said while reimbursement rates are an issue, his facility won’t refuse to accept residents because they are on Medicaid.
“That would go against our mission,” he said. “But I have to say there’s some validity to what Vintage Park is saying because, in reality, (Medicaid) reimbursement has been flat for quite some time and healthcare inflation runs about twice what it is for the economy at large.”
Jim Klausman, chief executive at Midwest Health, a for-profit operation active in four states and with 24 nursing homes and 11 assisted living facilities in Kansas, said the company shares Vintage Park’s concerns but has a different strategy.
“We understand — and we share — some of the frustrations being expressed by Vintage Park, but we think we have a better shot at changing the system from within rather than pulling out,” he said.
Midwest Health’s nursing homes have signed contracts with all three KanCare companies, he said. But Midwest chose to sign an assisted-living contract with only one: Sunflower State Health Plan.
“We’re still taking Medicaid,” for assisted living, he said, “but you’ll need to be on Sunflower.”
The decision to only sign with one KanCare plan, Klausman said, was meant to strengthen Midwest’s bargaining position.
“We’d rather negotiate with one company than three,” he said.
‘Uncertainty over reimbursement’
Debra Zehr, chief executive with LeadingAge Kansas, a trade group, keeps close tabs on the state’s nonprofit assisted living facilities.
“There’s a lot of uncertainty over reimbursement and the administrative costs that come with having to deal with three payers — the (KanCare) managed care companies — instead of one,” she said. “I don’t know of anybody who thinks they’re breaking even on Medicaid. It’s more of a community service than anything else. You do it because it’s the right thing to do.”
Rural hospitals could provide critical help addressing the state’s expected doctor shortage, according to Dr. Douglas Girod, the new executive vice chancellor of the University of Kansas Medical Center.
“This is one of those areas where if you really want to link physicians with where they need to be with funding of the educational enterprise…potentially community hospitals can step into the role,” Girod told KHI News Service.
KU officials also are planning a new $75 million medical education building on the Kansas City, Kan., campus to help train more doctors and are seeking funding help from the Legislature this year.
KU officials estimate Kansas will need 213 new doctors a year by 2030 just to maintain what is now a physician-per-resident ratio that lags the national average. To meet the national average ratio, Kansas would need about 285 new doctors a year by 2030.
Girod said community hospitals could help address doctor shortages in rural areas by funding residency slots through federal Medicare payments.
According to medical center officials, The University of Kansas Hospital pays for 280 residency slots, augmenting its federal funding with money from its clinical operations and with assistance to other hospitals
KU has 511 residency slots in Kansas City and 250 at its Wichita campus.
Kansas has done a good job trying to seed rural communities with more doctors, said Brock Slabach, senior vice president of the National Rural Health Association. He said KU’s campus in Salina was a good example of that.
National medical school accrediting bodies, Slabach said, worry about the training and oversight residents might receive in remote areas so have been reluctant to sign off on training programs outside metropolitan areas.
The federal government has also been slow to implement legislation authorizing rural training tracks, he said. And community hospitals have been reluctant to take on the responsibility because of the added costs of overseeing residents.
Though it can be hard to get them there, once young physicians arrive in smaller towns, they tend to energize the local medical communities.
“It stimulates the physicians in those communities,” he said. “They are challenged a bit in terms of their assumptions and what they have learned. They have someone coming out maybe with some different perspectives on things because of their more recent education.”
KU efforts to construct its new medical building hit a snag in the Legislature last week, when the Senate Ways and Means Committee voted to cut $10 million that Gov. Sam Brownback proposed for the project.
The House Appropriations Committee today approved the $10 million.
In his proposed two-year budget, Gov. Sam Brownback included $3 million in fiscal 2014 and $7 million in fiscal 2015 for KU's effort to build a new $75 million medical education building. The governor also endorsed giving the medical center $35 million in bonding authority for the project.
KU officials say they could train about 25 new doctors a year on the Kansas City campus after the improvements, and need the new facilities anyway or else the school's accreditation could be in peril.
Kathy Damron, a lobbyist for KU, said the facility is needed, in part, to integrate instruction of doctors, nurses and other medical staff, currently trained in separate facilities.
"It will allow the doctor to learn with the nurse, with the anesthesiologist and so on — all in a simulation lab. Right now, we train them all separately and throw them in the hospital and say 'now work together.' And that doesn't really work. That's the modality that schools of medicine are now moving to," Damron said. "The accreditors want to see that we're moving in the right direction to change the modality in which we're teaching our medical students.
Should the state funding come through, Girod said he was confident that KU could raise the $22 million it has pledged toward the building.
He said he would like to have the building ready by 2017, constructed on what is now a parking lot at the northeast corner of northeast corner of Rainbow Boulevard and 39th Street.
“When (donors) think about how they want to invest their funds,” he said, “they want to invest in an area where they are going to see some pretty tangible results. And I think it’s very easy to see a very tangible result from (the building). It will impact generations and that is something that will excite some potential donors.”
Girod also touched on other topics during the interview, including:
• How KU’s recent National Cancer Institute designation helps its education mission: “That creates a culture of clinical, intellectual curiosity that already we are seeing synergies from.”
• The burgeoning relationship between KU and Children’s Mercy Hospitals and Clinics in Kansas City, Mo.: “The potential for that collaboration to grow the research enterprise for both of our organizations is immense and it’s wonderful clinically and it’s great for the kids and it’s great from an education perspective.”
• Status of the proposed School of Public Health: “We have had the work group looking at the combination of feasibility, structure and then financing and we are working down that list. It’s a unique school in that it will involve several campuses…which is a much more dispersed model than a lot of places. It creates challenges but it also creates opportunities because each has different strengths, in part because each sits in a different part of the state.”
The Lawrence-Douglas County Health Department announced today that it has partnered with the University of Kansas to form the state's first "Academic Health Department."
Among other things, the research skills of the KU Work Group on Community Health and Development will be utilized to better gauge effectiveness of services and strategies deployed by the health department.
Dan Partridge, the health department's director, said the Academic Health Department would play a pivotal role in helping his agency evaluate and document the successes and failures of policies and systems that aim to improve community health.
“A major focus will be to answer the question: How well are community-based efforts working to improve health,” said Partridge. “We hope the answers will help inform future decisions promoting the health and vitality of Douglas County.”
The Academic Health Department will also function like a teaching hospital for KU students in applied behavioral psychology, the academic home of the KU Work Group, said Vicki Collie-Akers, who leads the group's research efforts.
“We hope to ultimately create a shared research agenda with the health department...to merge our goals with theirs,” said Collie-Akers, who will have an office at the health department.
The health agency and the KU work group already have a history of working together — most recently in facilitating a Comprehensive Community Health Assessment as part of the agency's work toward accreditation.
Among the short-term goals of the Academic Health Department will be implementation and evaluation of the county's first Community Health Plan, another component of the health department's work toward accreditation.
It's difficult to gauge how many Academic Health Departments there are in the U.S., said Kathleen Amos, who leads the AHD Learning Community for the Public Health Foundation in Washington, D.C. There are at least 36, from a list she's informally compiled, but she said that is likely far fewer than there actually are.
She pointed to the most recent National Profile of Local Health Departments (pages 71 and 72), which indicates that about 20 percent of health departments nationwide have worked with a four-year academic institution on program evaluation, and about 35 percent have some sort of written agreement with a university.
A Wichita lawmaker has introduced a bill that would require cities that fluoridate the water to notify users "that the latest science confirms that ingested fluoride lowers the I.Q. in children."
House Bill 2372 was offered by Rep. Steve Brunk, a Republican, who said he introduced the bill on behalf of Mark Gietzen, a conservative GOP activist and anti-abortion lobbyist also of Wichita.
But Brunk said he did not expect the bill to advance and that he had no interest in it himself.
"That was a constituent request," Brunk said. "As a courtesy, I gave him a bill introduction and told him that was as far as it goes. I'm not his champion of the cause," he said.
"I'm not aware of any interest in this bill at all (among fellow legislators). I'd be surprised if the (committee) chairman gives him a hearing."
Fluoridation has long been accepted by public health experts in the U.S. and elsewhere as an effective means to combat tooth decay, especially in children. Its use has been widespread among public water suppliers in the U.S. since the 1960s. According to the federal Centers for Disease Control and Prevention about 74 percent of the nation relies on fluoridated water supplies. The CDC has linked public fluoridation with an increase in the incidence of dental fluorisis, a condition that can cause tooth enamel to appear streaked but is not generally considered harmful to health.
Most research on the subject has shown municipal water fluoridation to be a safe and and effective practice. There are a few scientists who say their studies suggest otherwise, and that their findings have been marginalized by the broader scientific community.
Gietzen told KHI News Service he hoped to take advantage of the recent publicity surrounding Wichita's citywide vote on whether to fluoridate its public drinking water. Voters there rejected fluoridation, just as they did previously in 1978 and 1964. Wichita is among the few larger American cities that do not fluoridate public water supplies. The cities of Topeka, Lawrence, Manhattan and dozens of others in Kansas do add the CDC-recommended amount of fluoride to driking water. Many rural water districts also provide fluoridated water to their customers.
"The momentum of the Wichita fluoride debate (is) something we want to capitalize on," Gietzen said. "With everything — asbestos, lead, thalidomide, the drug we once thought was so good — when more modern science shows you that what you thought in the past was good and now you know it's not good, you need to put the brakes on it and stop harming people."
Gietzen cited a a 2012 study co-authored by a researcher at the Harvard School of Public Health that showed children in areas with high naturally occurring fluoride have significantly lower I.Q. scores than children in low-fluoride areas. He said it was that study that convinced him to vote against fluoridating Wichita's water.
"Eight months ago I didn't know how I was going to vote on the Wichita fluoride debate. I couldn't even spell fluoride, truth be known," Gietzen said. "If something opened your eyes and you realized you have knowledge of something other people are being harmed by and they didn't even know it, wouldn't you feel the obligation to at least let them know?"
The study by the Harvard researcher, however, mostly considered the effects of high levels of fluoride on brain development among children in China because that's where there are significant numbers of people exposed to high levels of fluoride, often from well water and not as the result of municipal fluoridation. The study's authors noted that it was difficult to find study subjects in other industrialized countries because children there aren't exposed to high fluoride levels in the water "even when fluoride is added to water supplies as a public health measure to reduce tooth decay."
A study released today by the Kansas Hospital Association says that expanding Medicaid eligibility to levels called for in the federal health reform law would pump more than $3 billion into the state’s economy and create 4,000 new jobs by 2020.
The study, done for the association by the Center for Health Policy Research at George Washington University and Regional Economic Models, Inc., also shows that expansion would save the state more than it would cost.
Tom Bell, the association’s chief executive, said the projected economic benefits were too significant to be ignored by Gov. Sam Brownback and legislative leaders as they consider whether or not to expand eligibility for the healthcare program that serves poor, elderly and disabled Kansans.
Brownback has been a vocal opponent of the Affordable Care Act but has not made a decision on Medicaid expansion, which was made optional for states as the result of last year’s U.S. Supreme Court decision upholding the law.
“I think from our perspective, it’s not unlike the state landing a huge federal contract,” Bell said.
The impact of the expansion on the Kansas economy could rival that of the National Bio and Agro-Defense Facility in Manhattan, Bell said.
“That’s the way we look at it, as an opportunity for our state,” he said.
Bigger impact in Kansas
Since Jan. 1 in Kansas, the Medicaid program has operated under the name of KanCare. Three health insurance companies are under contract with the state administer it.
The health reform law requires that the federal government cover state costs of expanding Medicaid for three years. After that, the federal share would recede gradually until it reaches 90 percent, where it would remain.
Currently, Kansas’ Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and only then if they earn less than 32 percent of the Federal Poverty Level (FPF) — currently $5,900 a year for a family of four.
Because those numbers are so low, expanding Medicaid would have a bigger impact in Kansas than in many other states by making all Kansans who earn up to 133 percent of FPL — $30,660 for a family of four — eligible for the program.
Various estimates suggest that expansion could add between 226,000 and 240,000 Kansans to the 380,000 now enrolled in Medicaid.
Net benefit to the state
A Kansas Department of Health and Environment report released last week estimated Medicaid costs would climb by $513 million over 10 years regardless of whether the state expanded eligibility for the program. That’s because heightened attention surrounding the expansion issue is expected to prompt many people who already are eligible but not enrolled to sign up.
Covering only those who are made eligible by the expansion would cost another $600 million over 10 years, the KDHE report said. Even so, the hospital association report said that expanding Medicaid would produce a net savings to the state of $82 million from 2014 to 2020.
“That’s front loaded into those first three years, but it’s still a substantial net benefit,” Bell said.
Brownback has not ruled out expansion but neither has his administration shown much, if any, enthusiasm for the idea. Reacting to the KDHE cost estimate, Sherriene Jones-Sontag, the governor’s chief spokesperson, said expanding Medicaid would affect the state’s ability to fund other “core responsibilities.” The impact would be even greater “if the federal government fails to keep its promise to pay for its part of the expansion,” she said.
Bell said administrators at the association’s 126 member hospitals understand Brownback’s concerns, which are shared by many legislators. But he said they believe the Medicaid expansion dollars are needed to offset the anticipated loss of other federal funds that hospitals have used to cover the cost of caring for the uninsured.
“From an economic perspective for our members — especially those that treat a higher number of uninsured — they think it makes great sense to take a serious look this and see if we can make it work,” Bell said.
After months of advisory committee haggling over what it should look like, state officials say they are ready to launch the pilot program that will pave the way for including long-term services for the developmentally disabled in the new KanCare program.
Now, all they need to start the pilot are participants.
A recruiting letter went out Friday, seeking organizations and individuals willing to volunteer, but representatives from the state’s developmental disability organizations said doubts remain strong among their members about the pilot in particular and KanCare in general. It seems that nobody, including administration officials, expects a throng of eager participants.
“The advisory committee talked about really wanting, hoping to have a broad representation of providers (in the pilot), including different types of providers,” said Shawn Sullivan, secretary of the Kansas Department for Aging and Disability Services. “I don't know that it’s necessarily as important to have numbers as it is to have different types. I’m hoping to have five providers, at least.”
The administration of Gov. Sam Brownback originally sought to have long-term services for the developmentally disabled included in KanCare when the managed-care program was launched Jan. 1. But groups, including parents, that represent the developmentally disabled, persuaded legislators to postpone that for a year.
KanCare is the governor’s ongoing remake of the state Medicaid program. Since it was launched a few weeks ago, virtually all the state’s 380,000 Medicaid enrollees have been assigned to health plans run by three commercial insurance companies.
The same legislative proviso that delayed the administration’s push to roll long-term developmental disability services into KanCare also called for the pilot program. But disagreement between the administration and advocates for the disabled over what the pilot should try to gauge or accomplish went on for months after the 2012 Legislature adjourned and still hasn’t been fully resolved.
What kind of pilot?
Advocates for the developmentally disabled said they wanted a pilot that would test the administration’s still-unproven theory that the KanCare insurance companies could effectively manage long-term or “non-medical” developmental disability services, producing healthier customers while cutting government costs yet presumably earning profits.
That ambitious set of pledges is something that hasn’t been solidly demonstrated anywhere in the country and sounds “too good to be true,” as Maury Thompson, former director of Johnson County Developmental Supports.
About 30 dental hygienists from around the state were in Topeka this week to ask their legislators to approve the licensing of mid-level dental providers.
A bill to license so-called registered dental practitioners was introduced last week. If it becomes law, it would allow hygienists with 18-months additional training to, among other things:
• permanently fill teeth,
• extract teeth,
• repair dentures, and
• temporarily crown teeth.
The Kansas Health Consumer Coalition, Kansas Action for Children, the Kansas Health Foundation — a major funder of the Kansas Health Institute — and other groups have supported the licensing of mid-level dental practitioners in Kansas, and organized today's visits by the hygienists.
Heidi Lowry and Tammi Engel were among those who traveled the farthest. They are from Atwood — a town in the northwest corner of the state, which is designated a "dental desert."
According to a 2011 report, at least 57,000 Kansans live in "dental deserts," areas where the closest dental office is at least a half-hour drive from the resident's home.
Lowry and Engel met with Sen. Ralph Ostmeyer, a Grinnell Republican, to tell him how licensing the dental practitioners would improve oral health in Rawlins County and others like it.
"It's not just access" to care, said Lowry, a trained hygienist who now spends most of her time as director of the Rawlins County Dental Clinic.
"With the current economic climate on the state and federal level, we're going to have to look at ways to be self-sustaining. Being able to use (practitioners) is going to go a long ways toward being able to provide those services and do it in an economic manner. That's just more fiscally responsible with our Medicaid dollars, and all the way around," Lowry said. "When you're just talking economics, a (practitioner) is not going to make the same wage as a dentist. And when we're a safety net clinic and write off a significant portion of services every year, it's going to make the safety net clinics more sustainable without state, federal or grant dollars. That's huge. We can continue to see those who don't have insurance and not tax emergency rooms."
Ostmeyer asked the women if dentists were any less opposed to the idea than they were several years ago when licensing dental practitioners was first proposed.
"Are you able to sit down with the Kansas Dental Association?" Ostmeyer asked.
The dental association opposes the measure, saying there are better ways to increase access to oral health care — including its Kansas Initiative for New Dentists, which would offer loan repayment and scholarships to dentists and students who agree to serve for at least two years in a dental desert. The dental association has scheduled an event at the Statehouse tomorrow to announce the first four recipients of awards under the program.
"I've talked with several dentists in our area and we don't have near as much fight back. I don't think they'd publicly say 'I support this' in front of the dental association, but they see the need," Lowry said.
It's not easy to recruit and keep a dentist in rural areas, Lowry said.
Before she and her supervising dentist arrived in Rawlins County in 2008, citizens there had been trying to lure a dentist for 10 years, she said.
"When you live in that rural of an area, there's things you just don't think about," Lowry told KHI News Service after her talk with Ostmeyer. "If you have to see a medical specialist, you're driving to Denver. There's concern with (obstetrics) care, if (a potential recruit is) young wanting to start a family," she said.
"We're 30 miles from the closest Walmart, shopping is not really available, there's no fast food per se...our movie theater is open Saturdays and Sundays. During the summer they show on Fridays but as soon as sports start up, they close," Lowry said. "You have to really want a rural, community-minded area."
One of the two dentists the community recruited using a school loan repayment program is leaving soon, she said.
"She's coming back to the city, to Kansas City. So we're going to be down to one, which is going to be difficult," Lowry said.
A different mindset
She said if practitioners were licensed, the needs of Rawlins County could be met with two of them in addition to the current three hygienists and dentist.
Among the needs that would be most immediately met: fillings in the baby teeth of children the clinic serves in schools using portable equipment. Currently the closest dentist who accepts Medicaid referrals is 60 miles away in Norton and only handles "extreme" cases.
Ostmeyer asked why it was difficult to get dentists to see Medicaid patients.
Lowry said Medicaid doesn't pay as well and "that's compounded by the fact that there's just a shortage of dentists in general, so their schedules are full seeing (patients who have) private insurance."
She said practitioners also would fill a need for caring for the developmentally disabled children and adults her staff treats.
"What we've found is that if we can see them on site, they don't have to have as much valium or other things to make them chemically relax, they don't have to be restrained. So if we could bring services to them, it would be much better," Lowry said.
"I've just found that the mindset of a hygienist, generally it's just a little bit different personality than dentists — one's a little bit more willing to go do the on-site, portable dentistry," she said.
Alaska was the first state to sanction licensing of mid-level dental providers in 2006, and only Minnesota has done so since.
Some experts at Kansas universities are questioning Gov. Sam Brownback’s plan to cut spending on established early childhood development programs in order to fund a proposed new initiative aimed at improving the reading scores of the state’s fourth-graders.
Though the governor hasn’t yet provided much detail on how the new Kansas Reads to Succeed program would work, he has said he favors requiring third graders to pass a reading test before being advanced to the fourth grade.
‘Irresponsible and cruel’
“Passing children up the grade ladder when we know they can’t read is irresponsible and cruel,” Brownback said in his State of the State speech to the Legislature last month.
But reading specialists at two Kansas universities said research has shown that holding children back a year often does more harm than good.
“Children who are retained, typically, are more likely to not graduate from high school,” said Suzanne DeWeese, a reading recovery specialist with the Jones Institute for Education Excellence at Emporia State University. The university trains many of the state’s K-12 teachers.
“Children who aren’t learning to read need better instruction, not a repeat of a curriculum that’s already failed them,” she said. “And the sooner they have access to that instruction, the better.”
Diane Nielsen, an associate professor of education at the University of Kansas, said waiting until students were in third or fourth grade to address reading deficiencies was shortsighted.
“To do what it appears the governor wants to do, it would need to be done in the grades below fourth, beginning with support in preschool,” said Nielsen, a specialist in reading instruction.
“The emphasis should not be on a single year’s test results,” she said. “It should be on early intervention because there are so many things that need to be in place before a child reaches the fourth grade. Reading is not the simple process that people tend to think it is. It can be very complicated.”
Brownback, who campaigned for governor promising to boost 4th grade reading skills, told KHI News Service that he has been disappointed by the proficiency ratings.
“They’ve been fairly level for a long time,” he said. “We need to do better.”
Sherriene Jones-Sontag, the governor’s chief spokesperson, said details of Brownback’s new initiative would be made public in a bill that would be introduced by a legislative committee probably sometime this week.
“We reviewed models for potential legislation from several other states, including Florida,” she said. “Some aspects will be similar, some will be different and some completely unique to what other states have done to help struggling readers.”
The governor’s plan has been endorsed by the Kansas Policy Institute, a conservative think tank based in Wichita.
“What we’ve seen in places like Florida, which has had practices like this in place for over a decade, is that when you set up the (reading) test in third grade, the (school) districts and teachers see the significance and start building in interventions early on,” said James Franko, the institute’s director of policy.
“So instead of waiting for students to reach the third grade, they’re taking a soup-to-nuts look at how they do reading for (kindergarten) through third grade, identifying those students who are struggling, and getting them the help they need so there isn’t this rude awakening when, all of a sudden, they get to the third grade and can’t read with their peers,” Franko said.
Officials at the Kansas Health Foundation announced Friday they will issue grants this year to support the formation and work of Food Policy Councils across the state.
According to a foundation request for proposal, it will accept applicantions for “capacity building” grants of $10,000 and policy implementation grants of $40,000 that will be available through 2016.
Only local, county or state government agencies are eligible to apply for the grants, which the foundation said are designed to increase access to and consumption of healthy foods.
Grant recipients would be expected to contribute staffing or some other support to the effort.
The RFP lists several activities as examples of objectives the foundation would like to see Food Policy Councils pursue. Those include working with school districts to restrict student access to unhealthy foods and collaborating with local officials to increase public transportation options for people who have limited access to supermarkets or farmers markets. Helping local governments establish policies that promote locally grown foods and lead to the establishment of community gardens were among the other sample objectives listed in the RFP.
Additional information on the Food Policy Council grants and an online application are available at the foundation’s website, kansashealth.org.
The Kansas Health Foundation established the Kansas Health Institute with a multi-year grant and continues to provide most of the institute’s funding.
There have been plenty of problems and frustrations. No one denies it.
But as Gov. Sam Brownback’s Medicaid makeover entered its fourth week, administration officials, some legislators and a variety of others involved with KanCare said they thought the massive changes underway in the $3.2 billion program so far have gone smoother than many expected.
KanCare, which launched Jan. 1, moved virtually all the state’s 380,000 Medicaid enrollees into health plans run by three of the nation’s largest managed-care companies: United HealthCare, Amerigroup and Sunflower State Health Plan, a subsidiary of Centene.
“I think we’re in the growing-pains phase,” said Mike Larkin, executive director of the Kansas Pharmacists Association, which months ago began preparing its members for the changes. “Some of our members are getting different answers on things, depending on who they call.”
Because people tend to see their pharmacists more often than other medical providers, pharmacies were among the first to file claims and otherwise deal directly with the new system.
Larkin said he expected to be “inundated” with calls from members dealing with KanCare problems the first week of January.
“I was pleasantly surprised that I wasn’t,” he said. “I think we were more prepared than maybe some other folks for the things that are coming down. There are some stipulations of the contract that the state signed with the MCOs (managed care organizations) that we’re still waiting to see fruition on…but as far as the pharmacies go, there are some frustrations but for the most part, I suppose it could be worse.
“I’m looking at mid-February. I was talking with a legislator and we agreed that if Feb. 15 comes and some things haven’t settled down, then we’ve probably got a problem,” Larkin said.
State officials anticipated there would be difficulties during the transition and took some steps to ease them.
First 90 days
For the first 90 days of KanCare — and in some instances longer — the state is requiring the insurance companies to comply with previously established "plans of care" for Medicaid clients in order to minimize disruptions to the patient's usual or expected services.
Also for the first 90 days, the state is requiring the companies to reimburse Medicaid services given by any medical provider regardless whether the provider has signed a contract joining the companies' service networks.
As the program's launch date approached, state and MCO officials began holding daily 9 a.m. teleconferences with Medicaid providers and beneficiaries to help troubleshoot problems as they arose.
State and insurance company officials answer questions from callers, make note of problems and sometimes post them to their respective online “issues logs," though state officials concede many problems marked "resolved" on the the logs have simply been brought to the attention of someone to work on, rather than fixed.
The most frequent, single response to callers during the daily calls has been “can we get back to you on that?” or words to that affect. But many callers also seem to go away satisfied with the answers they get.
One of those who called in recently was Vicki DeStefano of Fairway. She telephoned on behalf of her 53-year-old brother, Mike, who receives Medicaid-funded assistance after suffering a serious brain injury in a 2006 motorcycle accident that left him mostly unable to move or speak and eating through a tube.
He needs attention around the clock, she told KHI News Service in a later telephone interview, and before November there were six people being paid, not including her, to help care for him at different times of the day or week.
Now there is only one person to help her with her brother. The others left because they stopped getting paid. DeStefano said she is paying the remaining person out of her own pocket because some things she simply cannot do by herself.
She said the agency that handled the payments to the workers told her they weren’t getting reimbursed by the managed care companies. But DeStefano said she was more upset with the intermediary Financial Management Services (FMS) agency (commonly referred to as a “payroll agent”) than she was with United HealthCare, because the company seemed to be trying harder to help her and her brother.
She said her prior experiences with state officials and a succession of its contracting payroll agents had left her exhausted, frustrated and ready for any kind of change in the system.
“We really needed a change,” she said. “Whenever you have the government doing something, it’s a mess. I think we need a change, I just don’t think they did the research to make it go right…The state just dumped it on to all these MCOs and didn’t do anything to help them.”
DeStefano said she was alarmed by how unprepared many of the MCO employees seemed to be, but she said she expected things would only get better. She said she was impressed that the day after she called in to complain about her problems, a United representative called on her to see about fixing them.
Her problems weren’t resolved yet, she said, “but even when they can’t resolve it right away, they’re trying.”
She said she never got quick responses from the state, so the new attention from the MCO was welcome.
Cathy Harding is executive director of the Kansas Association for the Medically Underserved, which represents the state’s safety-net clinics. She also said she was pleased by the responsiveness of the MCOs.
“I think most people expected it wouldn’t be possible to implement a huge program like this without bumps in the road,” Harding said. “The thing I was concerned with (going in) was how responsive would the MCOs be when we bring them problems. In that regard, we have been extremely pleased. All three MCOs, when we bring things to their attention they have literally jumped right on it.”
Harding said there were ongoing transitional problems but that she expected things could be running smoothly within three months.
“This is a guess on my part,” she said, “but given how things are working at this point in terms of addressing issues, I’d be a little surprised if we don’t have all these kinks worked out in three months. Three months for a program of this size is certainly not bad. We’ll see.”
Among the frequent complaints or questions from Medicaid providers during the state’s daily teleconferences have been those about claims rejections or delays in payment from the MCOs.
The state health department earlier this month stopped analyzing HIV tests for many of the state's medium and small counties and also stopped providing rapid or oral test kits, which is creating a new burden for cash-strapped health departments and creating some uncertainty whether they can continue testing for the disease in some rural locations around Kansas.
Compounding the problem, some local department heads said, was the short notice they received that the services previously provided free to them by the state were being terminated.
Notification letters from the Kansas Department of Health and Environment went out in late November, they said, giving them only about five weeks, including the holidays, to make alternate arrangements in time for Jan. 1, when the new policy kicked in.
"It's another nail," said Julia Hulsey, director of the Reno County Health Department in Hutchinson.
Kansas routinely ranks low nationally in its support for public health agencies.
New cost for patients
Hulsey said her department was able to contract with a laboratory in Wichita that agreed to provide the testing supplies for free (though it will charge for the lab work) and so her agency plans to continue the tests but will start charging patients for them probably by Feb. 1, once she has a clear picture of her agency's new, added costs.
"I don't have that whole cost figured out yet," Hulsey said, "but, of course, it will be more than KDHE because they didn't charge for it."
She said her goal would be to price the tests as low as possible to not discourage people from getting them. She said the department historically has performed about 220 tests a year.
Dan Partridge, director of the Lawrence-Douglas County Health Department, said Lawrence Memorial Hospital agreed to help with the testing after KDHE withdrew the services, so it will only cost his agency about $9,000 a year to continue the testing instead of about $18,000. But he said the new obligation signals another state retreat from support for local health departments.
Urged to continue
State officials, in their November letter, urged the local departments to try to continue the services on their own.
KDHE "would like to encourage your agency to continue to provide HIV testing to clients requesting an HIV test, especially those reporting high-risk behaviors," the letter stated. "However, any test conducted at your agency beginning January 1, 2013, and continuing thereafter will need to be paid for by either your agency or by the client through insurance, public assistance programs, or out-of-pocket."
But a spokesperson for the state's local health departments said it would be difficult or impossible for some smaller departments to pay for the tests on their own.
"I suspect there will be some health departments in some areas that won't be able to find a workaround like Douglas County," said Michelle Ponce, executive director of the Kansas Association of Local Health Departments. "I couldn't give you a firm number, but in some of those rural areas they may not have another option for testing."
The state’s letter also included some cost-comparison information to help the local departments shop for testing materials, lab work and other necessities of the program.
Hulsey in Reno County said she ended up considering four or five outside laboratories between the time she got the letter and Jan. 1 when the state assistance stopped.
"We got very short notice on this," she said. "And then having to go negotiate for ourselves...you never know if you're getting the best price."
State officials said they had to reduce the services because of cutbacks in a federal testing program administered by the Centers for Disease Control and Prevention that has been reconfigured to focus on areas where the incidence of HIV/AIDS is greatest.
In the past, according to state officials, 40 local health departments received the free services. That number has been trimmed to 10, according to Ralph Wilmoth, director of the HIV/AIDS program at KDHE. The 10 county health departments that will continue to get the aid include Johnson, Sedgwick, Wyandotte and Shawnee, the state’s most heavily populated, and also Crawford, Pratt, Riley, Saline, Thomas and Trego counties.
The state also will provide the testing services to various organizations other than health departments in about a dozen counties. For example, in Douglas County the services will be continued for the Douglas County Aids Project, a non-profit group. In Reno County, the services will continue for the state prison in Hutchinson.
Wilmoth said the CDC made the program changes in anticipation of the full-scale implementation of the Affordable Care Act, which begins Jan. 1, 2014. Millions of Americans are expected to become newly eligible for Medicaid then and HIV testing is among the health services covered by Medicaid.
Linked to Medicaid expansion
But when the U.S. Supreme Court ruled on the health reform law, it concluded that each state had the option to not expand its Medicaid eligibility and Gov. Sam Brownback nor the Kansas Legislature have yet determined whether Kansas will broaden access to its program, which is known as KanCare.
Many Kansas hospital officials say they are worried that if state policymakers choose not to expand eligibility for the state’s Medicaid program, the hospitals will see a significant drop in the money they receive to help care for patients who can’t or won’t pay their medical bills.
Currently, 64 of the state’s 127 hospitals divide about $51.3 million a year in what are called Medicaid disproportionate share payments.
They use the money, a mix of federal and state dollars, to offset some of the costs of caring for the uninsured.
“It’s a significant amount of funding for us,” said Bruce Witt, director of governmental relations at Via Christi Health in Wichita.
In the current fiscal year, Via Christi Health is expected to receive almost $13 million from the disproportionate share payments, the most of any health care provider in the state.
Under the Affordable Care Act, also known as Obamacare, those payments are to be significantly reduced, starting in October.
“We’re being told that ‘disproportionate share’ won’t be completely phased out, but that roughly 50 percent will be going away,” said Tom Bell, chief executive of the Kansas Hospital Association. “It may end up being somewhere between 50 and 75 percent. We don’t know at this point.”
Though Via Christi could expect to lose the most dollars, the smaller, rural hospitals likely would be the hardest hit proportionately based on an analysis done for the KHI News Service by its parent organization, the Kansas Health Institute. The analysis calculated the likely revenue hit on each Kansas hospital based on recent payment histories, bed counts and inpatient stays.
State option on Medicaid
The law’s design, Bell said, preceded the U.S. Supreme Court’s June 28, 2012 ruling that gives states the option of choosing to not expand their Medicaid coverage to include non-disabled, childless adults whose incomes fall below 133 percent of the federal poverty level.
Since the ruling, governors in at least 10 states – Alabama, Georgia, Idaho, Louisiana, Maine, Mississippi, South Carolina, South Dakota, Oklahoma, and Texas - have said they will not expand Medicaid eligibility.
“Our lieutenant governor is saying he’s not sure that DSH (disproportionate share) is going away because the (U.S.) Supreme Court has said the federal government can’t penalize states for not going along with the Medicaid expansion,” said Shawn Rossi, a vice president with the Mississippi Hospital Association.
“We don’t know if that’s a correct assumption,” Rossi said, “but we are for sure telling our legislators that if DSH goes away, we’re definitely going to need something to take its place. We see a very large number of people who are uninsured.”
Brownback looking it over
Kansas’ Gov. Sam Brownback has been an outspoken opponent of the Affordable Care Act, has not yet decided whether to implement the Medicaid expansion.
A recent survey has found that half of Kansas adults gamble about once a month and that almost one in 12 admits to having bet more than they could afford to lose.
“It’s a real problem,” said Joyce Markham, an addiction counselor and president of the Kansas Coalition on Problem Gambling. “This affects not only the gambler, it also affects family members, our friends, and our co-workers through bankruptcies, crime, domestic violence and health care costs.”
Markham said she knew of several families that had lost their farms, homes, and life savings due a father or mother’s addiction to gambling.
The survey, commissioned by the Kansas Department for Aging and Disability Services, also found that while a large majority of state’s gamblers said they did not have a gambling problem, 13 percent of the respondents said they had “been affected” by someone - spouses, family members, friends and co-workers - who did.
Conducted in October and November, the poll involved telephone calls to 1,600 randomly selected adults. Each respondent was asked 96 questions.
Buying a lottery ticket was considered a form of gambling.
“There is so much information here, it’s a bit overwhelming,” said Doug Ballou, a managing partner with Whitworth Ballou, a Kansas City marketing firm that assembled the questionnaire and oversaw the interviews.
Ballou presented an overview of the findings during a Wednesday morning meeting of the Kansas Coalition on Problem Gambling.
KDADS officials said they would use the survey to put together a policy on how best to spend the state’s problem gambling fund, which is expected to reach $8 million in the fiscal year that begins July 1.
Kansas law stipulates that 2 percent of the net revenue generated by the three state-owned casinos – Kansas Star Casino in Mulvane, Boot Hill Casino in Dodge City, Hollywood Casino in Kansas City – be spent on programs and services for people with addictive behaviors: alcoholism, drug abuse and problem gambling.
Net revenue is defined as the slot-machine and table-game income minus payouts.
In an email sent to members of the Kansas Association of Addiction Professionals last month, a KDADS official said there likely would be less money for prevention and treatment services in the proposed budget for fiscal 2014, which begins July 1, 2013. The amount of the reduction, if any, remains unclear.
Gov. Sam Brownback is expected to release his proposed budget on Jan. 16, the day after his state of the state address. The Legislature is then free to add or subtract from the the governor's spending plan.
In the current fiscal year, the 2 percent set-aside is expected to generate about $7 million, most of which is used to underwrite Medicaid-funded drug and alcohol abuse programs. KDADS treatment and prevention efforts receive about $750,000.
Several coalition members said expected the governor to propose eliminating state-funded support for prevention and treatment services.
The state’s toll-free hotline for problem gamblers (1-800-522-4700) fielded 691 calls last month.
A week into major changes of the Kansas Medicaid program questions persist about whether a new consumer advocate will have the freedom and the resources to do his job.
Lawrence attorney James Bart was recently hired as the ombudsman for the new KanCare program being implemented by Republican Gov. Sam Brownback. Officials say the Jan. 1 expansion of managed care to include virtually all the state’s Medicaid enrollees is intended to slow the growth in Medicaid costs and improve the care provided to the more than 380,000 low-income, elderly and disabled Kansans in the program.
But some legislators and consumer advocates are questioning whether housing the ombudsman’s office in one of the state agencies responsible for KanCare implementation will hinder Bart’s effectiveness. They also question whether he will have sufficient resources to handle what could initially be large numbers of consumer complaints with the new system.
Bart, the only full-time employee in his office at the Kansas Department for Aging and Disability Services, was asked directly about the adequacy of his resources today during a meeting of the KanCare Specialized Care and Network Issues Workgroup in Topeka.
Sheldon Weigrau, a workgroup member, said if only 1 percent of the state's Medicaid enrollees filed complaints with the ombudsman, that would mean at least 10 complaints or problems a day to handle. He questioned whether Bart would have the resources to deal with that many of them, "otherwise, you're going to be overwhelmed."
Bart said 10 issues landed on his desk during the first working week of KanCare, which ended Jan. 4, and all had been resolved. And he said he had assurances from KDADS Secretary Shawn Sullivan that he could draw on on more of the agency's resources if needed.
"I can't solve every issue," Bart said. "But I can be the grease in the wheels. If it gets to the point where I feel I can't deal with the issues with the resources I've got, then I'll go get more resources."
Question of independence
Sen. Laura Kelly, a Topeka Democrat, is among the legislators asking questions about the ombudsman's office.
“It’s just beyond me to see how someone who is housed in an agency and who is dependent on that agency for the resources they need to do their job can be truly considered to be independent,” Kelly said after the issue was raised at a recent meeting of the Legislature’s Joint Committee on Health Policy Oversight.
Preferred provider networks can help seniors save money on their prescription drugs.
If a senior’s Medicare Part D plan includes a network of preferred providers and if they have their prescriptions filled at one of the participating pharmacies, they get a discount. That’s how the networks work.
But most of the participating pharmacies are large, corporate owned stores in towns large enough to have a Walmart, and owners of smaller, independent pharmacies say the chains' Medicare arrangements are hurting their businesses.
Charles Bankes, a pharmacist and owner of Bankes Drug in Abilene, said he doesn’t have much use for the networks.
Unlevel playing field
“They’re what’s going to drive independent pharmacies out of business,” said Charles Bankes, a pharmacist and owner of Bankes Drug in Abilene. The Medicare plans are "essentially telling everybody that it’s in their best interest to go to one of the big chain stores. The playing field isn’t level anymore."
Bankes said he was especially upset to learn that AARP’s new Medicare Part D plan, which takes effect on Jan. 1, includes a preferred network.
“They don’t come out and say you have to go to Walmart,” he said. “They just say it’ll cost you less if you go to Walmart or Walgreens or wherever.”
Bankes said he would continue filling his AARP customers’ prescriptions, but he’s not in a position to match the chain stores’ discounts.
“We’ve been cut out of the process,” he said, referring to small-town, independent pharmacies like his.
Chellie Ortiz, vice president of operations for the Kansas Independent Pharmacy Services Corp., said there are some independent pharmacies in the preferred networks. But most never get the chance.
'Totally shut out'
“We can’t make a blanket statement that applies to every single network that’s out there, but the large majority of independent pharmacies that we see are not even being invited or given the opportunity to participate," she said. “It’s not that independent pharmacies are saying, ‘No, we can’t meet those (discount) rates,’ it’s that they’re totally being shut out and not being provided opportunity to participate. There may be some that are saying they can’t or they won’t meet the rate, but they’re not the majority.”
Initially, a handful of Medicare Part D plans – Humana, most notably – offered preferred networks. Now, the networks are in most of the 30 plans being marketed in Kansas. The networks’ discounts vary from plan to plan.
“Last year is when they really took off,” said Brian Caswell, a pharmacist with Wolkar Drug in Baxter Springs. “It’s all based on the assumption that if you take your prescriptions to one of the big-box stores, you’ll end up spending a bunch of money on something else while you’re there. It’s to get you in the door. The chains can afford to do that. A lot of the independents can’t.”
AARP’s Medicare Part D plan is managed by UnitedHealthcare, one of the nation’s largest health insurers.
Saving members money
Sarah Bearce, a spokesperson for the company, defended that network in an email to KHI News Service.
“UnitedHealthcare is committed to developing new and innovative ways to improve health outcomes and save our members money," she said.
“Our preferred pharmacy network will help us accomplish this in 2013 by providing our members with access to a large number of pharmacies where they can choose to save money on their prescription drugs,” Bearce wrote. “We intend to continue working with retailers and pharmacies - including those that are not currently part of our preferred pharmacy network - to bring additional savings to our members.”
Morgan Murray is too young to have any idea who Doogie Howser is, but the 16-year-old from Shawnee is cut from a cloth similar to the prodigy doctor in the '90s TV show.
Even while finishing high school and getting a jump on college, Murray finds time to be flown across the country several times a year to help teach doctors twice her age how to perform challenging tracheal intubations, a procedure to get oxygen to patients with blocked airways.
"It's a very high-stress, very time-oriented procedure," said Murray. "I am helping teach the doctors how to intubate using high-fidelity simulators. I act as their nurse, getting them anything they need. Then I help debrief and tell them what they can do better."
Murray came into the teaching opportunity while sitting in on classes, which were taught by her mother. Two years ago, the instructor in the nurse role was out sick, and Murray seized the opportunity to fill in.
Now Murray is seizing another opportunity to get a jump on her career at the Kansas Academy of Mathematics and Science.
The two-year program is a sort of fast-track boarding school at Fort Hays State University. Each year, up to 40 high school juniors from across the state move into a campus dorm and complete their last two years of high school coursework while also taking college math and science courses.
Murray said that the academy — often called KAMS by students — provides an environment where staff and other students drive each other to set goals high.
"I've been wanting to pursue medicine since I was in third grade," Murray said. "KAMS has pushed me to do even more than I thought I could. I've done more in this semester than I thought was even possible."
Plugging the brain drain
Murray is one of 68 students currently enrolled in the academy. Another 53 students have graduated from KAMS since the first class in 2009.
The Kansas Legislature founded KAMS in 2006, in part to give students like Murray a learning opportunity in Kansas that would challenge the state's most talented students, said director Ron Keller.
"The academy was formed to keep the students here in the state — to keep intellectual capital from leaving Kansas, to keep from losing our best and brightest kids," Keller said.