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.
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.”
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.
The people who run the state’s only medical school say its national accreditation falls in jeopardy or is lost, if money isn’t raised for a new, $75 million structure at its Kansas City campus.
“If you're not an accredited medical school, your students can't take board examinations. Your graduates cannot get into residency programs that are accredited. And in most jurisdictions if you can't sit for your boards and you don't graduate from an accredited residency program you can't practice (medicine), you can't get a license. So accreditation is a huge deal,” said Dr. Glen Cox, the dean in charge of keeping the school OK with the Liaison Committee on Medical Education, the national group that certifies medical schools.
The current education building on the school’s Kansas City campus was built in 1976 and officials here say if it isn’t obsolete it is nearly so, especially given the changes happening in the ways doctors and other health professionals are trained.
“A building built in the 1970s just can't fit the technology needs of today,” said Dr. Steven Stites, acting executive vice chancellor of the University of Kansas Medical Center, which includes the medical school. “We have a structural problem and we can’t renovate it. It would cost more to fix it up than it would to replace it.”
Lecture halls, even in the first year of study, now are considered less important to learning than small practice rooms that allow for simulations that mimic the conditions students — as doctors — will face when they encounter real patients. Also, with growing emphasis on coordinated care within the health care industry, schooling now focuses increasingly on teamwork, not just among fellow medical students but also drawing in nursing students and other health-care trainees.
The school has some spaces for that sort of teaching by doing in small groups, but not enough, according to the people in charge. The accreditation process is so meticulous, as described by Cox, that it even dictates how much private space and storage must be allowed for each resident.
Cox said he is among the few people at the medical school to remember the accreditation problems it experienced in the 1990s, a years-long ordeal he said he would prefer not to live again. And that was before he was the administrator tasked with keeping those things in order.
Need for more docs
Besides warding off accreditation woes, a new school would allow for training more doctors, KU officials said. Experts across the country for years have warned of doctor shortages that have since arrived and are growing and of the need to expand medical schools to slow or reverse that trend.
KU between 1998 and 2007, according to medical school statistics, graduated an average of about 165 medical students per year and 41 percent (an average of about 67 graduates per year) stayed in the state.
The new building would allow the school to have 25 more students per class year in Kansas City and — after counting graduates from expanded satellite campuses in Wichita and Salina — the state should see 96 new KU-trained doctors a year practicing in the state by 2016, according to projections prepared by KU. That would be a net gain of almost 30 doctors a year.
With a generation of baby-boom doctors retiring or soon to retire, many Kansas towns struggle to recruit new doctors. A disproportionate number of the doctors working in the state’s rural and underserved areas are KU graduates.
There are about 259 doctors per 100,000 U.S. residents. In Kansas, however, there are only about 213 doctors per 100,000 residents. The state also is below the national average when it comes to primary care doctors.
According to KU estimates, the state will need 213 new doctors a year by 2030 just to maintain the state’s current below-average ratio. To match the national average, it would need about 285 new doctors a year by 2030.
The tricky part
It’s been known since Coronado traipsed the Plains that gold doesn’t always turn up in Kansas. And, unfortunately, Dr. Glen Cox did not win the Lottery last week (he said), so KU is struggling to come up with a way to pay for the school building that KU and other higher education officials say it must have and that the state needs.
Amid national concerns that the seriously mentally ill are dying from preventable diseases, a leading Kansas healthcare philanthropy is about to make a down payment on a multi-year initiative aimed at integrating physical and mental health services for safety-net patients.
Within the next couple weeks, the Sunflower Foundation expects to open a competitive grant program that Chief Executive Billie Hall said likely would provide more than $1 million in funds to selected health providers focusing on integrated patient care. Foundation officials expect to award the grants by March.
“When we made the decision to get into this particular area,” Hall said, “we knew it would be a long horizon. We know we are in for five, maybe 10 years, depending on how things go in our state.”
The foundation’s board chose the initiative as a major priority about 18 months ago.
To date, Hall said, the foundation has spent about $50,000 sending some providers from different Kansas clinics to visit Cherokee Health Systems in Tennessee, which has 43 clinical sites in that state and a history of melding medical and mental health services.
Integration can mean having mental health and primary medical care agencies housed in the same building, said Melody Martin, a program officer with the foundation. But that is not the only way to do it, she said.
For instance, community health centers in Lawrence and Newton now have social workers or behavioral health specialists who work alongside the clinics’ medical teams.
At Heartland Community Health Center in Lawrence, behavioral health specialist Karin Denes-Collar technically is employed by Bert Nash Community Mental Health Center, which is located several blocks to the west of the clinic. But her office is at Heartland, where she consults daily with the medical staff about the conditions of various patients.
For example, she said, a patient with diabetes might also suffer depression in ways that could hinder the treatments for the underlying medical conditions. A homeless man with a chronic physical malady likely also struggles with a range of other problems that compound the illness. Assistance with those problems might best come from a social worker.
Reconnecting kinds of care
Area providers and national experts alike say that better coordination of care is essential to proper treatment for the mentally ill.
In an April 2009 paper, the National Council for Community Behavioral Healthcare said that persons with serious mental illness were dying 25 years earlier than the rest of the population largely because treatable conditions — such as diabetes and cardiovascular disease — had gone unmanaged.
“The bottom line is that the mind and body are connected,” said Tim DeWeese, director of clinical services at the Johnson County Mental Health Center in Mission. “And so the more physically healthy you are, the more mentally healthy you are going to be and vice versa. I think it’s really just reconnecting the two things. I don’t know where we got off base.”
The Sunflower Foundation is building upon a pilot project started two years ago by a subsidiary of the Association of Community Mental Health Centers of Kansas in collaboration with the Kansas Association for the Medically Underserved (KAMU)
Providers from nearly a dozen communities, including Heartland in Lawrence, were part of the pilot, said Connie Hubbell, director of governmental affairs at KAMU. The participants collected data for about a year starting in early 2011.
Undertaken with little funding, Hubbell said the pilot yielded results that were encouraging nonetheless. For instance, data compiled on 81 patients indicated an 8 percent reduction in monthly expenses per patient.
“So we know it’s out there,” she said. “We know it can happen. The integrated model is cost effective, it does save money, and it’s much more appropriate for the patient.”
Integration in action
One of the biggest challenges, Hubbell said, is successfully melding the consultative atmosphere of mental health with the often-frenetic pace that goes with providing primary care in a safety-net clinic.
Jennifer Brull’s father needed urgent medical attention.
Brull, herself a physician, was helping him collect everything he needed, including his most recent laboratory and scan results. Then she learned that one set of her father’s X-rays were at a hospital four hours away.
"We had to drive to pick them up," she said, recalling the incident, which occurred earlier this spring. "It was a real pain in the butt. You know, it's during a stressful time and we were dealing with a bunch of other things. This was just one more thing that we have to deal with, something that should have been easy. There's no reason in this day and age that we shouldn't have been able to accomplish that electronically.”
Dr. Jennifer Brull, who practices family medicine in Plainville, is a national leader in adopting electronic health records.
It isn’t the technology itself that is the barrier to more medical providers exchanging electronic records, she said, but the lack of a secure network to transmit them without risking patient privacy.
"We said, 'Just email it — it's fine, we'll sign a waiver.' They said they just couldn't do it," Brull recalled of the hospital’s refusal to transmit her father’s X-ray records and spare the family the long drive.
Developers of a new statewide digital health records exchange say the needed secure network is coming to Kansas this summer. They call it a groundbreaking event that is expected to improve patient care and help cut medical costs by avoiding redundant and ineffective treatments. It’s also expected to reduce errors.
The statewide health information exchange is scheduled to go live July 1, allowing medical providers registered with the network to share and search for patient records.
Dr. Robert Moser, secretary of the Kansas Department of Health and Environment, said the exchange would safeguard patient privacy.
"We can assure patients that this information will be secure and safe and only available to those providers that need it, and at the time they need it," he said.
Patient information available on the network at first will be limited to demographics, medications, allergies, lab results and medical history, including diagnoses, procedures, surgeries and immunizations. But officials at the Kansas Health Information Exchange Inc. predict the system will grow to include more kinds of information, such as a doctor's notes or dictation recordings.
Substance abuse data will not be available on the network unless explicitly authorized by a patient.
About a third of Kansas patients receive care from a provider who is or will be connected to the exchange in the near future, officials said.
Benefits of exchange
As it is more widely adopted, health information exchange, or HIE, will take the place of paper records, which are typically transferred via fax, discs, mail or by patients themselves. And quicker access to more complete patient information should translate into benefits for patients.
"Right now we wait sometimes a month or more to get records," Brull said. "That time delay certainly impacts how you provide care to that patient."
She said the current paper system relies heavily on the patient to relay information from one care provider to the next. But too often patients don't know exactly what was done or learned by another provider.
"If you know real information, you're a lot less likely to order another test," Brull said. "That's what the free exchange of information gets you — you've helped the patient and eliminated costs."
Less paperwork also will mean less administrative cost, she said.
"I hope people look back 20 years from now or 50 years from now and say, ‘This was when health care in the United States changed. There's way less cost and better health care,’" Brull said.
→ Continue reading about health information exchange at khi.org/HIE — including information about network security and privacy concerns that patients need to know.
New privacy notices
Starting June 1, patients of Kansas health care providers who are connected to the new statewide network will receive privacy notices telling them that their health records may be shared electronically, under the same legal protection that currently applies to their paper-based health records. Those who don’t want their records to be available on the network must mail in an "opt-out" form, which is available at the website KHIE.org.
Brownback administration, state's top insurer see potential savings in patient-centered model.
Larry Rahn had never heard of a "patient-centered medical home," though his doctor's practice here is one of a handful certified in Kansas.
Nonetheless, the 49-year-old John Deere mechanic said he had noticed something different about Dr. Jerad Widman's approach to medicine and that his health has improved in seven years under Widman's care.
"He goes the extra mile. He's been working on my bad cholesterol for two years and finally has it where he wants it," Rahn said. "He kept hammering on trying to eat right. After a couple years, I finally paid attention. You actually do feel better."
For Widman, the patient-centered medical home approach is about "proactively taking care of the whole patient, not just their chief complaint," he said.
"When people are sick enough to actually come into the doctor, the great majority of the time there's more than just a cold going on," he said. "Patients present with complaints. But most patients don't even know what all needs to be managed. If we leave it to them to tell us what to take care of, we don't take care of enough."
Widman said electronic health records are essential to the way he runs his practice, which is certified by the National Committee for Quality Assurance at Level 3, the highest level.
He said having and maintaining an electronic health record for each patient is the foundation of coordinated care.
He also uses the system to track and organize the care his patients receive outside his practice, which helps him minimize redundant treatments. The digital records also help his staff prepare for patient visits and deliver care at "the top level of their training," he said.
For example, his aides can perform a routine foot exam on a diabetic patient or update a patient's vaccinations even though the appointment initially was scheduled to check blood pressure — all before the doctor enters the exam room.
Proponents of patient-centered medical homes say that coordinating care through a single primary care provider will improve patient health and efficiency of delivery and reduce costs systemwide. Better management of chronic diseases and other preventive care will lead to fewer costly hospitalizations, they say.
Among medical home proponents are officials in the administration of Gov. Sam Brownback. They've indicated that medical homes will be central to their plan to overhaul Medicaid.
If every American had access to a medical home, national health care spending would drop by 5.5 percent, or $67 billion per year, according to estimates by the American Academy of Family Physicians.
Widman said he had no doubt medical homes would yield significant savings as more providers adopt the concept. But so far, he said, there is very little financial incentive for doctors to do so. Doctors make more money the more patients they see — and less money if they spend more time with each patient, he said.
"My only incentive has been top-notch, quality care for my patients. It has actually been to my financial detriment to do it," Widman said. "It's easily cut my take-home pay by 25 percent. That would be a conservative estimate."
As long as doctors are primarily paid for services — not outcomes — Widman said he doesn't foresee the medical home concept catching on.
"My hope is that the reimbursement structure is going to change to incentivize the comprehensive approach as opposed to the volume approach," he said.
A three-year pilot project under way in Kansas ultimately may lead to the state's largest private insurer changing its reimbursement structure.
The Patient Centered Medical Home Initiative — launched last summer by a coalition of the state's leading medical societies with underwriting from three Kansas health foundations — is intended to help eight practices overhaul their offices into certified medical homes.
The practices are working with web-based TransforMED to complete "mini-quality-improvement projects" with the goal of becoming certified at the top level, said Carolyn Gaughan, executive director of the Kansas Academy of Family Physicians.
TransforMED is a subsidiary of the American Academy of Family Physicians devoted to helping doctors get their practices certified as medical homes.
Getting a practice certified as a medical home is not easy, Gaughan said.
"They can't just close the practice and become a patient-centered medical home — that isn't how it works," Gaughan said. "It's stressful, and they're pretty brave to be dedicated to doing this. They're the laboratory in Kansas."
As part of the project, Blue Cross Blue Shield of Kansas is paying the eight pilot practices for implementing various patient-centered medical home practices.
Blue Cross spokeswoman Mary Beth Chambers said data gathered during and after the project would help guide how the company reimburses health care providers in the future.
"We feel fairly confident that there needs to be a move away from the fee-for-service model if we're going to — as a state — get control of health care costs," Chambers said. "The purpose of the pilot is to see whether this sort of model will provide better coordinated quality care that will ultimately lower the cost of health care. If you put more emphasis on the front-end care, prevention and wellness, does that save money over time?"
Last month, Blue Cross affiliate Wellpoint Inc. announced it would begin raising reimbursements for primary care providers who implement certain medical home practices, and even more for those who demonstrate savings. Most qualifying providers in the 14 states Wellpoint serves will see a 10 percent payment increase, and some could earn up to 50 percent more.
Chambers said that while there is a good deal of sharing data and best practices amongst members of the Blue Cross and Blue Shield Association, she could not say how Wellpoint’s move might affect Blue Cross of Kansas’ planning.
“Ultimately it’s up to each independent Blue plan to make the decisions that are best for their service area,” she said.
Verdict is out
Tina Davis is the director of four rural health clinics that — along with the county hospital — comprise the Ellsworth County Medical Center, one of the eight pilot sites.
She said "the verdict is out" on whether medical homes will lower the overall cost of health care.
"If we do our job well, it will reduce the number of in-patient stays and ER (emergency room) visits, so obviously our revenue from the hospital side will decrease. But on the outpatient side, because we're doing a better job maintaining those patients ... our revenue should be greater," Davis said.
Dr. Jennifer Brull's practice in Plainville is another pilot site. She said she's working toward medical home certification solely to improve patient care. But she said the bottom-line benefit of doing so is a question of when, not if.
"I think that people who are smart are going to say, 'I see it coming' — I see more money coming from (operating a patient-centered medical home) and I'm going to jump on that. But you got to have faith so you can be there when the money comes. Otherwise you're going to be playing catch-up," Brull said. "Blue Cross is putting their money where their mouth is; they are actually trying to pay to improve care."
KanCare and medical homes
Using medical or health homes to coordinate care and ultimately lower costs is part of Gov. Sam Brownback's Medicaid makeover, called KanCare. At the Feb. 3 announcement of KanCare's executive reorganization order, Cabinet member Shawn Sullivan said health homes were a major component of the plan to move all those on Medicaid into managed care.
→ Continue reading about Gov. Brownback's plans for health homes in Kansas — and find links to resources cited in this story — at khi.org/pcmh.