Legislature eases physician assistant rules; nurse practitioners' prescription power, Medicaid prompt-payment bills, others linger

By Molly Burchett and Al Cross
Kentucky Health News

The Kentucky General Assembly has joined other states in easing the restrictions on physician assistants’ medical practice, but has held up a similar move for advanced registered nurse practitioners. Both issues relate to the shortage of medical practitioners in many Kentucky counties, and the quality of medical care.

The Senate added the physician assistant language of Senate Bill 43 to House Bill 104, an art-therapy bill, in order to preserve an agreement between the Kentucky Medical Association and the Kentucky Academy of Physician Assistants. It will repeal the law that bans PAs from practicing for their first 18 months unless a physician is on site; one will still have to be available by telephone. The amended bill has been sent to Gov. Steve Beshear for his signature or veto.

The amendment was used because the House had tacked onto SB 43 an amendment from advance practice registered nurses that would have repealed the need for them to have a collaborative agreement with a physicians to prescribe non-narcotic drugs. The KMA opposes that idea.

"It's looking like the doctors win," said Sen. Julie Denton, R-Louisville, who favors the repeal. "I'm not hopeful" it can pass, she said, but added that some physicians also favor it: "With Obamacare coming in, we're going to need all the front-line physicians we can get." Leading opponents of the measure, Republicans Katie Stine of Fort Thomas and Carroll Gibson of Leitchfield, didn't return a call seeking comment.

Nurse practitioners say that SB 43 is necessary to allow them to fill health-care gaps in rural Kentucky and address the state's shortage of primary-care providers. The Kentucky Coalition of Nurse Practitioners and Nurse Midwives says in an article prepared for Kentucky newspapers that NPs have never been required to practice under physician supervision and 17 states allow full prescribing authority for non-scheduled medications.

The Medicaid prompt-payment bill, HB 5, went to a conference committee after the House refused to go along with Senate changes, and may be considered when the legislature returns later this month, ostensibly to consider any bills Beshear vetoes. The bill would apply prompt-payment laws to managed-care organizations and would move Medicaid late-payment complaints to the insurance department; those are now handled by the Cabinet for Health and Family Services, which administers Medicaid.

In the final crunch to pass legislation before the veto recess, lawmakers attached seven health care-related bills to HB 366, which had focused on identifying congenital heart disease in newborns. It had 10 additional measures "hung on it like a Christmas tree before the free conference committee of House and Senate members," reports Ryan Alessi of cn|2's "Pure Politics."

The bills still hanging on the measure, dubbed the "healthy Christmas tree," are:

• HB 187, addressing a free prescription-drug program for under-insured Kentuckians.
• HB 79, which would exempt licensed health care providers from being disciplined for prescribing naloxone in the event of an overdose.
• HB 387, which aims to provide nutritional supplements for low-birth-weight newborns.
• SB 201, which addresses licensed diabetes educators.
• SB 38, to require Medicaid to accept provider credentialing by a Medicaid managed-care organization.
• SB 108, relating to managed-care contracts with the IMPACT Plus program, a behavioral health program for children.

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Poll shows Kentucky health-care providers often fail to discuss HIV testing with patients

A new poll suggests that most Kentucky health-care providers follow guidelines for discussing HIV screening with their patients, despite the the importance of early treatment to prevent its progression to AIDS.

Although the Centers for Disease Control and Prevention recommends routine HIV screenings for most patients, just 32 percent of Kentucky adults aged 18 to 64 report discussing HIV testing with their medical provider, according to the Kentucky Health Issues Poll.

About 40 percent of Kentucky adults reported they had never been tested for HIV. It’s estimated that 4,500 Kentuckians are living with HIV infection and it is estimated nationally that one in five people who have HIV do not know they do.

“It made headlines earlier this month when a little girl - the second person in history - was cured of HIV. As exciting as this development was, for most people, HIV remains a life-long condition that must be managed through medication to keep it from progressing to AIDS. The CDC’s recommendations are meant to improve the overall population health by detecting HIV so treatment can begin,” said Dr. Susan Zepeda, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsored the poll.

“It appears that Kentucky providers are either not adhering to the routine screening recommendations or not communicating this message clearly to patients,” she said.

The poll, co-sponsored by the Health Foundation of Greater Cincinnati, was taken Sept. 20 through Oct. 14 by the Institute for Policy Research at the University of Cincinnati. A random sample of 1,680 adults throughout Kentucky was interviewed by landline and cell telephones. The poll's margin of error is plus or minus 2.5 percentage points

Poll finds four out of five Kentuckians are comfortable seeing a nurse practitioner or physician assistant for routine care

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

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

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

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

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

The poll, co-sponsored by the Health Foundation of Greater Cincinnati, was taken Sept. 20 through Oct. 14 by the Institute for Policy Research at the University of Cincinnati. A random sample of 1,680 adults throughout Kentucky was interviewed by landline and cell telephones. The poll's margin of error is plus or minus 2.5 percentage points. (Read more)

Frontier Nursing University in Hyden helps bring better family health care to rural America with distance learning

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

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

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

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

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

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

First showing of 'Remaking Rural Health' is tonight on KET; focuses on people who are making a difference

The spotlight often shines on rural Kentuckians' alarming health problems, but far less attention goes to the people in those communities who are making a difference. "Remaking Rural Health: A KET Special Report" focuses on the advocates who are making inroads in improving conditions in these areas. The first airing of the report is at 9 p.m. Eastern Time tonight.

The report focuses on the expanded use of nurse practitioners, specifically those at Alliance Coal LLC, where a team of practitioners, overseen by Dr. Raymond Wells, run on-site clinics at seven mine sites in the state. It also looks at people like Dr. Phillip Bale of Glasgow who are focused on prevention. Bale runs one of the only "prevention clinics" in the state, spending nearly 30 minutes with each of his patients to identify risks for conditions like heart disease.

With boots on the ground, the goal of the University of Kentucky Rural Cancer Prevention project is to promote prevention by increasing testing and screening for four major cancers, educating through the use of Facebook and text messaging, and having advocates go to places like Walmart to reach out to people.

Awareness is another focus of these advocates. In Montgomery County, the Hispanic population prompted the health department to start the Promotora Program, in which leaders of the Hispanic community are trained in health issues in order to share their knowledge with members of the community. And the Hazard-Perry County Community Foundation aims to build health values in the community to try to change health outcomes.

The report will air again at 10 p.m. EST Monday, Feb. 13, and will be available online. For more information, click here.

Nurse practitioners endorse new plan to fight prescription drug abuse, ask to be on board that will recommend standards

UPDATE, Oct. 14: Gov. Steve Beshear's executive order did not create a slot for advance-practice registered nurses on the advisory council, which will have representatives appointed by Beshear and nominated by the Kentucky Board of Medical Licensure, the Kentucky Board of Dentistry, the Kentucky Board of Nursing and the Kentucky Board of Pharmacists. "The medical licensure boards will send the governor a list of nominees for the slots on the advisory council, and the governor will name the full council within the next few weeks," a release from Beshear's office said.

The Kentucky Coalition of Nurse Practitioners and Nurse Midwives is endorsing the plan announced Thursday by state officials to fight prescription drug abuse, but asking that advance-practice registered nurses (APRNs) who prescribe controlled substances be added to the advisory board that will set standards for over-prescribing.

“We believe that the addition of APRNs who are prescribing controlled substances for different populations will be very helpful . . . in creating guidelines for generally accepted practices,” Julianne Ewen, president of the 2,049-member coalition, said in the release, available here.

Advance practice registered nurses may prescribe controlled substances within certain limits. Wendy Fletcher, past president of the coalition, noted that APRNs make up 9.9 percent of all prescribers in Kentucky but prescribe only 3.7 percent of controlled-substance prescriptions in the state and “have demonstrated that they are responsible prescribers.”

While fewer than a third of Kentucky doctors use the Kentucky All Schedule Prescription Electronic Reporting database, "APRNs who prescribe controlled substances have eagerly made use of the KASPER tracking system," the release said. The coalition wants the legislature to require that all APRNs who have a Drug Enforcement Agency number register for a KASPER account.

Three Ky. physicians and one nurse practitioner investigated for high numbers of prescriptions for antipsychotic drugs

State and federal officials are investigating three Kentucky doctors and one nurse practitioner because of the unusually high amounts of antipsychotic drug prescriptions they write for Medicaid patients.

In 2008 and 2009, the four wrote the most prescriptions in the state for Abilify, Geodon, Seroquel, Zyprexa and risperidone, antipsychotic drugs that can cost up to $10 a pill, The Courier-Journal's Laura Ungar reports.

Somerset psychiatrist Dr. Zev Zusman wrote 6,556 prescriptions in 2008 and 2009, resulting in $2.2 million in Medicaid charges.

Mount Sterling's Dr. Samuel Welch, left, wrote 5,881 prescriptions, costing taxpayers $1.9 million.

Deborah Bradford, an Owensboro-based nurse practitioner and psychologist, wrote 4,279 prescriptions, at a cost of $1.2 million.

Paducah-based Dr. Duncan Darnell, a child and adolescent psychiatrist, wrote 3,536 prescriptions, costing $1.1 million.

Welch and Darnell defended their practices. Welch, the medical director of Pathways Inc., said he sees about 20 patients a day in a 10-county area. "The biggest chunk of what I do is see patients for medications," he said, adding that other psychologists provide talk therapy.

Darnell, the medical director at Four Rivers Behavioral Health, said he prescribes for more than 1,000 of his own patients, as well as sometimes prescribing for patients cared for by another psychiatrist and a nurse practitioner. "The folks I end up seeing are often very mentally ill," he told Ungar. "For me, medicines are used as a last resort."

Tracking the prescription levels is part of "a federal review into concerns about over-prescribing, waste and health care fraud in an era of tight government budgets," Ungar reports. Sen. Chuck Grassley, R-Iowa, is leading the review, and has asked every state to list the top 10 prescribers for certain medications. (Read more)

Foundation matches Social Innovation Fund money to create grants for improving health services in seven Kentucky counties

The Foundation for a Healthy Kentucky today announced four equal Social Innovation Fund grants totaling $1 million to improve access to health services, reduce health risks and disparities, and promote health equity in Jefferson, McCreary, Wolfe, Powell, Montgomery, Bath and Menifee counties. The projects are expected to serve nearly 9,000 people in the next year.

Home of the Innocents in Louisville will establish a dental clinic at the newly opened interdisciplinary Hockensmith Pediatric Assessment Center. The program will provide dental services to children in state care, children with special health care needs, and other children and families served by the Home and its partner agencies.

St. Joseph Health System, based in Lexington, will establish primary care clinics in Powell and Wolfe counties, both rural and low-income. These satellite clinics will be staffed by nurse practitioners and will utilize telemedicine to collaborate with physicians and specialists at a central location.

Cumberland Family Medical Center, based in Burkesville, will establish a nurse-managed health center and rural training program for nurse practitioners and physician assistants. Funds will be used to expand the scope of services provided in McCreary County to include x-ray and utilize health IT to connect with other CFMC sites. This will be the county's first x-ray, reducing travel for local residents who previously had to travel ouside the county for x-ray services.

The Montgomery County Health Department in Mount Sterling will establish a health education and navigation program to serve a low-income population in Montgomery, Bath and Menifee counties. Four full-time health navigators will be employed to serve the community by assessing individual needs and linking patients with services.

Each $250,000 grtant includes $125,000 from the Foundation for a Healthy Kentucky. As an endowed public charity, the foundation was able to provide the matching funds that were required to secure the Social Innovation Fund award for Kentucky. Learn more about the grants here.