13 of Kentucky's 71 rural inpatient hospitals at risk of closing, with six of them at immediate risk, a national policy center estimates

Center for Healthcare Quality and Payment Reform map

By Melissa Patrick
Kentucky Health News

Thirteen of Kentucky's 71 rural inpatient hospitals are at risk of closing, and six of those are at immediate risk of closing, according to the latest analysis of Hospital Cost Reports by the Center for Healthcare Quality and Payment Reform, a policy center that says it works toward patient-centered, affordable health care. 

The report does not name the 13 hospitals, but it does offer a wealth of financial information about most rural hospitals in Kentucky and every other state, including critical access hospitals and rural emergency hospitals that are not designated as rural.  

The center says its analysis is based on financial data from the most recent cost reports that hospitals must submit annually to the Centers for Medicare and Medicaid Services. The financial report shows rural hospitals' operating margins, profits and losses on patient services and revenues and costs on patient services and those that are not directly tied to patient care. 

Low reimbursement rates from Medicare and Medicaid are often blamed for why rural hospitals have such ongoing financial troubles, but the center expands that list to all types of insurance, saying in the report, "losses on private insurance patients are the biggest cause of overall losses" in at-risk hospitals. 

"The only way to prevent more closures of services and hospitals is for all health insurance plans, including Medicare Advantage plans, commercial insurance plans, and Medicaid programs, to pay rural hospitals enough to cover the higher costs of delivering services in rural areas," the center says in a news release. 

The center also states that the federal  Rural Emergency Hospital program, which forces rural hospitals to eliminate inpatient services in order to receive large federal grants, "is not a solution to these problems" because it eliminates much-needed services in a community. Kentucky has one such hospital, Crittenden Community Hospital in Marion, Ky. 

Instead, the center calls for change in how rural hospitals are paid and proposes a method of payment that calls for all payers to start providing "standby capacity payments" to rural hospitals to cover the fixed costs of essential services such as emergency care, inpatient care and maternity care. 

What the numbers show

According to the center's "Data on Rural Hospitals" financial status report, using data from the three most recent years for which Hospital Cost Reports are available, 15 rural hospitals in Kentucky lost money (defined as "negative total margin");  19 others lost money on patient services, but not overall; and 10 lost money on patient services and overall. 

The 15 listed with negative total margins are in Fulton, Pineville, Irvine, Carlisle, Madisonville, Shelbyville, Albany, Manchester, Owenton, Mount Sterling, Marion, Burkesville, South Williamson, Campbellsville and Russellville.  

The 10 cited that lost money on patient services and overall are in Pineville, Irvine, South Williamson, Marion, Mount Serling, Shelbyville, Albany, Owenton, Manchester and Fulton. 

The 19 listed that lost money on patient services, but not overall are in Martin, Columbia, Prestonsburg, Benton, Hazard, Paintsville, Danville, Greenville, McDowell, Harlan, Salem, Middlesboro, West Liberty, Carrolton, Russell Springs, Monticello, Tompkinsville, Hardinsburg and Whitesburg.

The report explains several ways that a hospital could lose money on patient services, but not overall. 

"Many hospitals have managed to remain open despite losses on patient services because they receive local tax revenues or state government grants," says the report. "However, there is no guarantee that these funds will continue to be available in the future or that they will be sufficient to cover higher costs." 

For example, the report notes that the federal assistance many hospitals received during the pandemic has ended, which has resulted in more than one-third of rural hospitals losing money overall in 2022-23. 

It also says that some hospitals have financial reserves to offset the loss of inpatient services, adding that "the hospitals at greatest risk of closing have more debts than assets . . . to offset their losses on patient services for more than a few years."

What's Kentucky doing? 

The previous report said 16 rural Kentucky hospitals were at risk of closing and 10 of those at immediate risk of closure, higher than this year's 13 and six, respectively.  

More information is needed to know why the number of at-risk hospitals in Kentucky is lower than they were in last year's report, but what is known is that Kentucky legislators have passed laws to help support them. 

Kentucky Cabinet for Economic Development table 

For example, in 2020 they created the Kentucky Rural Hospital Loan Program, a revolving loan fund for distressed rural hospitals, and in 2021, funding of $20 million. 

The original bill allows the Cabinet for Economic Development to provide loans to struggling hospitals to maintain or upgrade facilities; maintain or increase staff; or provide health services not currently available. The low-interest loans can run up to 20 years and are available to hospitals in counties with fewer than 50,000 people.

So far, eight Kentucky hospitals have been approved for projects, with $7.2 million in funds authorized. They are Pineville Community Health Center, Baptist Health Deaconess Madisonville, Rockcastle Hospital & Respiratory Care Center in Mount Vernon, Trigg County Hospital in Cadiz, Crittenden Community Hospital in Marion, Ohio County Hospital Corporation in Hartfort, Deaconness Union County Hospital in Morganfield and ARC Health Systems in Ashland.  

Of this list, the hospitals in Pineville and Madisonville and the Rural Emergency Hospital in Marion have negative total margins. 

Laws have also been passed to allow Kentucky hospitals to get more money from Medicaid, basing payment on the "average commercial rate" instead of the current Medicaid rate, which is often below that amount. This legislation was passed under two bills -- the first in 2021 that addressed higher rates for inpatient care and the second, passed in 2023, that addressed higher payments for outpatient care, which is the one that is most beneficial to rural hospitals. 

More recently, the Kentucky Hospital Association gave a detailed overview of the 340B drug discount program at the July 30 Interim Joint Committee on Health Services and asked for help to secure these payments with contract pharmacies as a way to ensure rural hospitals can keep providing many of the programs they support. 

KHA President Nancy Galvagni explained that the 340B program requires pharmaceutical companies to sell drugs to covered hospitals and their contract pharmacies at their best price, allowing Kentucky hospitals to then invest their 340B savings to provide patient services that otherwise would not be available. 

For example, she said the savings from the 340B program allows some hospitals to "keep the doors open." Others, she said, use it to offer low-cost medications for the uninsured, cancer programs and hepatitis C clinics, and to support their charity care.   

Galvagni added that because some hospitals don't have in-house pharmacies, they contract with local pharmacies to provide the medications covered by the 340B program. 

"The problem we face is the large pharmaceutical manufacturers have refused to deliver the medications covered by the 340B program to our contract pharmacies," she said. "That refusal by these large, highly profitable multinational corporations to deliver medications to the contract pharmacies creates massive losses for the critical programs our patients need. Without the savings from the 340B program, critical health services will become unaffordable, and hospitals simply won't be able to provide the care that is funded from the 340B savings." 

In closing, Galvagni asked the General Assembly to enact legislation to require the delivery of these 340B medications to contract pharmacies in Kentucky, as six other states have already done and 19 more are working on. 

The center's figures can be downloaded at https://ruralhospitals.chqpr.org/Data1.html.

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Kentucky maternal health roundtable explores ways to improve Kentucky maternal health; two stories from Kentucky Lantern

Centers for Disease Control and Prevention photo

The Kentucky Lantern offers two stories this week about maternal health in Kentucky, both by Sarah Ladd. One is about a roundtable held in Louisville that was moderated by Carole Johnson, the administrator of the Health Resources and Services Administration for the Biden administration. The other is a Kentucky Lantern Q&A with her. 

The roundtable discussion touched on several topics, including the Health Access Nurturing Developmental Services program, more commonly known as HANDS; praise for Rep. Kim Moser's, R-Taylor Mill, "Momnibus" bill that passed during the 2024 legislative session; and the need for a comprehensive approach toward improving the state's maternal mortality rates, including addressing social determinants of health, which includes things like transportation and housing, and the role that substance-use plays in such deaths.

Kentucky's maternal mortality rates are dismal, according to Ladd's reports. And, they are worse for women of color than white women. 

"The 2023 March of Dimes report showed the state once again had high maternal mortality, which was worse for Black Kentuckians. The state has a maternal mortality rate of 38.4 deaths per 100,000 live births, higher than the national rate of 23.5 deaths per 100,000 live births," Ladd reports.

She adds, "A 2023 state report on maternal mortality also showed substance-use disorder contributed to nearly 60% of all maternal deaths. Most maternal deaths in Kentucky — 88% — are preventable, a report from the Cabinet for Health and Family Services said." 

The links to the stories are below. 

https://kentuckylantern.com/2024/08/09/a-kentucky-lantern-q-a-with-federal-health-

https://kentuckylantern.com/2024/08/08/roundtable-explores-ways-to-improve-kentucky-maternal-health/

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Grant applications open to nonprofits that work with substance-use disorder and mental health in underserved communities

Foundation for a Healthy Kentucky photo 

By Melissa Patrick

Kentucky Health News

The second round of Foundation for a Healthy Kentucky grants to expand services and programming for substance use recovery and mental heath support in minoritized communities is open through Sept. 13. 

The Funding for Recovery Equity and Expansion program, dubbed FREE II, will provide at least 10 grants in the amount of $50,000 to nonprofit organizations, with priority given to grass-roots organizations, Black-led organizations and organizations that primarily work in minoritized, under-resourced and BIPOC communities. BIPOC stands for Black, indigenous and people of color. 

Among other things, the program aims to fund projects that work toward expanding services and programing for substance use recovery and mental health support in marginalized communities and to reduce the stigma associated with assessing evidence-based interventions that support substance use recovery and mental health. 

"With this project, we aim to reduce overdose deaths and increase the overall well-being of these historically under-resourced Kentucky communities," says the release.

This program is in partnership with the Kentucky Opioid Response Effort and the Kentucky Department for Health and Family Services. 

According to the website, the collaboration will only fund projects that:

• Use a trauma-informed and resilience-informed care approach to reduce premature death of BIPOC Kentuckians
• Provide culturally responsive, evidence-based prevention, mental health treatment and recovery support services to BIPOC Kentuckians
• Strengthen treatment and prevention infrastructure through collaborative projects centering BIPOC voices

Go to healthy-ky.org/free-program to learn more  about the program and to access the application. 

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Addiction Recovery Care says it’s cooperating with FBI investigation into possible fraud

Addiction Recovery Care, Kentucky’s largest provider of
drug and alcohol treatment, has offices and other facilities
 in Louisa. (Kentucky Lantern photo by Matthew Mueller)

By Deborah Yetter
Kentucky Lantern

Kentucky’s largest provider of addiction treatment services, Addiction Recovery Care, or ARC, is the subject of an FBI investigation into possible health care fraud, according to a July 30 post on a website of the federal agency’s Louisville office.

ARC, which is funded almost entirely through Kentucky’s Medicaid program, has not been charged with any crime but the agency is asking people with information to fill out an online form “if you believe you were victimized by ARC or have information relevant to this investigation.”

ARC, a for-profit company based in Louisa, and whose CEO and affiliates have emerged as prolific political donors in recent years, said in a statement from spokesman Kyle Collier that it is cooperating with the FBI.

“We have recently learned that there is a federal investigation into ARC,” the statement said. “As we all know, healthcare is one of the most highly regulated fields in the country, and addiction treatment is among the most highly scrutinized healthcare services. ARC is a trailblazer in the field of addiction services. We are confident in our program and in the services we offer. We, and our legal counsel, are cooperating fully in the investigation.”

Collier directed further inquiries to ARC’s chief legal officer, Jessica Burke, who provided a similar statement.

ARC has developed a reputation for aggressive expansion since it was launched by Tim Robinson, a Lawrence County lawyer who founded the company with a single halfway house for alcohol treatment in 2010. Fueled by the availability of new Medicaid funds for substance use disorder treatment since 2014 under the Affordable Care Act, ARC operates some 1,800 treatment beds in 24 counties and reaches hundreds more clients through outpatient services, the Kentucky Lantern reported in July.

Last year, ARC took in $130 million in Medicaid funds, the government health plan which gets most of its money from the federal government, making it by far the state’s largest provider of substance use services.

Robinson and his wife, Lelia, own ARC and some related entities which provide them with an annual income of $533,400, according to a 2022 tax filing of a related non-profit company, Odyssey Inc.

The company has been singled out for praise by politicians including Kentucky Gov. Andy Beshear, who spoke at an ARC ribbon cutting for a new ARC facility in March.

“With the help of organizations like ARC, we are working to build a safer, healthier commonwealth for our people,” Beshear said.

He also praised Robinson, ARC’s founder, in his State of the Commonwealth speech in January.

“With us today,” Beshear said, “is Tim Robinson, founder and CEO of ARC, an essential partner in our fight against addiction. … I’m proud to say we now have more treatment beds per capita than any other state in the country.”

From mid-2021 through the end of 2023 Robinson, his corporations and employees gave at least $252,500 to political committees supporting Beshear, according to reporter Tom Loftus’ analysis in the Kentucky Lantern of campaign finance records.

The donations to Democrat Beshear were a shift in the giving pattern for Robinson, a lifelong and loyal Republican. He also gave big to Beshear’s opponent in the 2019 governor’s race, Republican incumbent Gov. Matt Bevin.

The Lantern’s analysis shows that — including money contributed to Beshear committees — Robinson, his corporations and employees have made at least $570,000 in political contributions over the past decade as his for-profit company grew.

He also has donated to Kentucky Republican lawmakers, including some who wrote recent letters on ARC’s behalf, asking that rate cuts proposed to ARC and other addiction providers be suspended until further study.

The rate cuts of 15% to 20% proposed by three of the six private insurance companies that process state Medicaid claims became public recently at a legislative hearing. ARC and another provider told lawmakers that such cuts would devastate Kentucky’s efforts to turn the tide of addiction to drugs and alcohol.

“Kentucky has made significant strides in access to treatment,” Matt Brown, chief administrative officer for ARC, told a July 30 legislative committee. “With these cuts, it could completely set back addiction treatment in our state 20 years.”

Six national insurance companies known as managed care organizations, or MCOs, handle the majority of the state’s $16 billion a year Medicaid business. Under contracts with the state, they are paid a fixed rate per member to cover the cost of care.

Brown, the ARC official, told lawmakers this is no time to cut payments for addiction services, citing some indicators of success.

Brown noted that overdose deaths in Kentucky have declined for the past two years after years of rising. Kentucky also has the most treatment beds per resident, most of them through ARC, he said.

The state’s latest annual overdose report, released in June, shows a decrease in deaths to 1,984 from 2,200 the year before, a decline of 9.8%.

In a statement released after the hearing on the cuts, the Kentucky Association of Health Plans, which represents the MCOs, said its members “are proud to work collaboratively with quality, trustworthy providers of behavioral health and substance use disorder treatment” and access to those services is “top of mind” to ensure those in need receive care.

“Health plans strive for the best networks possible and are encouraged by the state to prioritize plan member outcomes and value-based care,” it said.

The FBI posting on the website seeking information on ARC does not provide further information about the nature of the investigation,

A spokeswoman did not immediately respond to a request for comment.

A questionnaire people are asked to fill out includes several questions including whether they have been or are a patient at ARC and if so, what services were received. It also asks whether the person responding has ever made a complaint before about ARC and if so, to whom.

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EMS staffing shortages are at crisis level, says Kentucky EMS board chair

Centers for Disease Control and Prevention photo

By Melissa Patrick
Kentucky Health News

Kentucky's Emergency Medical Services are facing severe staffing shortages, with low pay, "abysmal" reimbursement rates and high turnover identified as the key reasons for the problem.

"We lose more paramedics every year than we gain, unfortunately. . . . We're hemorrhaging providers, we're losing more paramedics than we can replace,"  Kentucky Board of Emergency Medical Services Chairman John Holder told lawmakers at the July 30 Interim Joint Committee on Health Services.

Holder said Kentucky has an attrition rate of 21%, which means two out of 10 of their emergency medical technicians, commonly known as EMTs, will not return or certify again next year. Further, he said only 40% of their EMTs work with an EMS service. 

"That means that less than half of those who are certified are actually going to work on an ambulance and treat members of their community," he said. 

Holder said that even with new rules that allow only one paramedic per service, regardless of the size of the service, some EMS services can't even manage that level of staffing

“We're receiving regular calls from EMS services who are saying gentlemen were having to self-report that we cannot meet the staffing requirement as set by regulation, which means they don't have enough paramedics to staff their ambulances,” Holder said. “It truly is a crisis. I mean, we have services that are going to shut down if we can't find a solution to this problem.”

EMS staffing challenges have been ongoing, while the need for services increase. According to Holder's presentation, there were "31,006 more requests for ambulance transport annually than five years previous." 

One of the key challenges is poor compensation, which Holder said is directly related to "abysmal reimbursement."

 

"These EMS services are losing money when they make ambulance runs, which is hard," he said. "So a lot of folks will tell you, 'Oh, well just pay them more. We wish we could. And we would if we could, but with reimbursement the way it is, the pot is just not big enough to draw any more funds out of." 

Another challenge, he said, is poor access to education. 

"So especially in our in our rural parts of the state, our providers are having to travel hours, multiple times a week to try to find this education and they're either unwilling or unable to do it in a lot of cases because they're needed at home," he said. 

Holder said that while there have been efforts to address the workforce shortage, such as decreasing the initial requirements for EMS educators, removing licensing fees for newly certified providers, allowing reciprocity for providers from other states and decreasing the number of providers required for coverage, it hasn't been enough to fix the problem. 

What they need, he said, is increased reimbursement for services in order to increase wages and to secure funding for additional training sites and student scholarships. 

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First Federally Qualified Health Clinic residency program opens in Kentucky, with hopes of bringing more rural doctors to state

By Melissa Patrick
Kentucky Health News

Kentucky's first residency program operated by a Federally Qualified Health Center opened July 1 in Northeast Kentucky, with hopes that the resident doctors will set up practice in rural Kentucky after they complete their training. 

The PrimaryPlus Family Medicine Residency Program will be headquartered in Maysville, Ky.  The primary focus of the residency program will be family medicine with plans to use specialty services such as obstetrics and gynecology and pediatrics to provide residents with a well-rounded experience.

Dr. Tyler Elam

Dr. Tyler Elam, director of the residency program, said FQHCs can play an important role in training physicians because of the populations they serve, who are largely indigent, uninsured or underinsured.  

"I think there is a greater . . . mutual benefit for having the learners present in an FQHC," he said. "It helps us close care gaps for the indigent, while also being able to train new physicians.   

Kentucky's program is one of 81 Teaching Health Center Graduate Medical Education programs that operate in 24 states and Washington, D.C., said Elam. 

Research shows that medical students who trained in rural areas are almost twice as likely to practice in rural areas whether or not they grew up in a small town, a topic explored in a blog post from the National Rural Health Association. Further, studies shows that physicians from rural backgrounds were more than twice as likely to practice in a small town, compared to urban counterparts.

And that is the goal of the PrimaryPlus residency program. "That really is part of our mission, is to train them here and keep them here," Elam said. 

There is a great need for rural primary care physicians in Kentucky, according to the 2022 Kentucky Physician Report from the University of Kentucky Center of Excellence in Rural Health. The report says 43 of 120 Kentucky counties meet the criteria for a primary care physician Health Provider Shortage Area. Nearly 73% of of Kentucky's 2,741 primary care physicians practice in urban counties despite the majority of the population living in rural counties.  

PrimaryPlus's residency program will bring four new primary care residents into the state each year.

The first class of residents are Dr. Devaki Dravid and Dr. Jerry Eddis, both from Pennsylvania. Devaki received her medical degree from Philadelphia College of Osteopathic Medicine and Long received his from American University of the Caribbean School of Medicine. Dr. Brion Long is from Breckinridge County, Ky. and Dr. Sara Roberts is from Bath County, Ky. Both Long and Roberts attended the Kentucky College of Osteopathic Medicine at the University of Pikeville. 

Elam said the new residency slots will help to meet the ongoing demand for more primary care physicians, especially as baby boomers continue to need more care.  

"There's not necessarily enough residency spots to keep up with the increasing medical school class sizes. And so, you know, there's like a supply and demand mismatch as a result," he said. "So the more residency spots we can open up, it definitely closes that care gap downstream."

Already, Elam said the resident doctors have been able to close some of the care gaps in the community and have contributed to the wellness of the medical community, who often work short-staffed. 

"The residents are thriving and loving it here," he said. "They'll come to my office and be like, 'Man, this is so great. I didn't know that learning could be like this. I feel like I'm part of the team. I feel like I'm making a difference. And I feel like I'm learning simultaneously.'"

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Study finds blood test diagnosed Alzheimer's disease 90% of the time; early diagnosis is crucial with new medications available

2024 Alzheimer's disease facts and figures
special report graphic

By Melissa Patrick
Kentucky Health News

A blood test can diagnose Alzheimer's disease better than a memory specialist or a primary care physician, according to a new study. 

The study, published in the Journal of the American Medical Association, found that the blood test, called PrecivityAD2, was 90% accurate in diagnosing Alzheimer's disease, compared to a 61% success rate among primary care doctors and a 73% success rate among memory specialists. All of the physicians used standard clinical methods for diagnosis that did not include brain scans or spinal taps. 

The researchers at Lund University in Sweden followed 1,213 people with an average age of 74 who were undergoing cognitive evaluations in both primary care and specialty clinics in Sweden.

Dr. Greg Cooper, director of the Norton Neuroscience Institute Memory Center in Louisville, explained that there are protein biomarkers that are indicative of Alzheimer's disease and can be identified through a a spinal tap, which is invasive, or a brain scan called a PET scan, which he said are not always available, are expensive and are not well-covered by insurance. 

But now, he said, there is a blood test that can accurately detect these biomarkers. The blood test works by measuring a combination of two ratios within a blood sample, including the phosphorylated tau protein and two amyloid-beta proteins, both considered  hallmarks of Alzheimer's disease. 

"Most people would prefer a blood test over a spinal fluid exam, a spinal tap," he said. 

Cooper added that the blood test should be used only on people who show signs of memory loss or have a diagnosis of mild cognitive impairment or dementia. In this group, he said, "It is a very accurate test." 

Further, he said this blood test will help people get an early diagnosis, which is needed to qualify for the two new drugs approved to modestly slow the symptoms of Alzheimer's: Leqembi and Kisunla. At this time, Cooper said it can take months or even years before a person can receive a diagnosis. 

"As newer medications become available . . . we need to do a better job of identifying people very early on, when they are the best possible candidates for these medications that we believe actually slow the progression of the disease."

According to the Alzheimer's Association, nearly 7 million Americans are living with Alzheimer’s disease, with this number projected to rise to nearly 13 million by 2050. In Kentucky, the association reports that 81,000 people aged 65 and older are living with Alzheimer's.

Cooper said the Norton memory center is already using this blood test, but there remains some barriers. 

"The biggest barrier right now has been in terms of payments," he said. "So we are using this exact same test that was used in this study and the results are really quite good. But payment is an issue.

Insurance does not always cover this and so there is often an out-of-pocket expense."

He said he is hopeful that with studies like this one and future U.S. Food and Drug Administration approval, insurance will eventually pay for it. " I think it is only a matter of time before insurance starts paying for it, "he said. "At this time, it's just simply too new." 

He said it "remains to be determined" if primary care doctors should do this blood test, largely related to their ability to do cognitive memory testing in their practices. With the advent of these new medications that require early diagnosis, he said there is a sense of urgency to diagnose people early on and a patient's first point of contact is often their primary care provider. 

"The worst thing in the world is to tell someone had I seen you six months or a year earlier, you might have been a candidate for one of these new treatments -- and now you're not," he said. "Tests like this will help accelerate that process and allow more people to benefit from these therapies."

Recognizing that many people are afraid of getting an Alzheimer's diagnosis, Cooper said: "I would simply argue that not receiving a diagnosis, if you have that underlying disease, doesn't make the disease go away. You can't ignore it. It will catch up with you eventually. But now, we have opportunities to take a proactive approach. Maybe we can't cure it, but we can do things that meaningfully impact the disease and can meaningfully impact and promote our quality of life. So it is an awful diagnosis, I can't take that away. But we can't help unless we take that first step. And so always keep in mind, there may be things that we can do. Don't run away from that." 

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