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Guest blog by Carolyn Dennis, MS, RD, LD, Health Advocate

The 2012 Session of the Kentucky General Assembly was anything but dull and will likely be remembered for a few well-publicized issues that found victory or fell by the wayside.   Fortunately, lawmakers did the right thing when they passed an important yet fairly quiet bill that will go a long way toward helping all Kentuckians access lifesaving treatments and medications. 

By passing Sen. Julie Denton’s Senate Bill 114 lawmakers have given Kentuckians a strong new tool to make sure they get what the doctor ordered.  

There was much discussion in Frankfort about health insurer policies that limit a patient’s access to care, such as complicated prior authorizations and mandatory step therapies.  While much is left to do on the Medicaid managed care front, legislators wisely passed SB 114 to protect patients from at least one of these potentially harmful practices.

Step Therapy, or “fail first” policies require patients to first try a less expensive medication and possibly “fail” on their treatment before being allowed access to the medication originally prescribed by their provider. This can become particularly dangerous for patients suffering from serious mental or physical illnesses.

In the case of those with epilepsy, failing first on a medication can mean very significant consequences.  Many patients with epilepsy may be stable on one medication for years, granting them freedom from debilitating seizures. However, once they are switched to a different medication per their insurer’s restrictions they can suffer what is known as a “break through” seizure. Depending on the circumstances, just one break-through seizure can have serious repercussions even after years of stability.  It can mean losing a job, a driver’s license, suffering serious injury or even loss of life in extreme cases.

One of my Kentucky clients recently expressed how issues with her medication lead to having break through seizures, shortly after having brain surgery to help stop her seizures, which now means she is no longer permitted to watch her infant unsupervised. In other cases, break through seizures have occurred while someone is driving, which has caused car wrecks, potentially leading to injury for both the patient and others, as well as putting them at risk of a fatal injury. 

SB 114 establishes a method for prescribers to override insurance company restrictions when there is evidence that the alternate, cheaper medication will be ineffective or cause an adverse reaction to the patient. It also decreases the time frame that patients must fail on a medication before they are permitted to take what is prescribed by their provider. This is good public policy that protects patients. 

Since 1996, the Epilepsy Foundation of Kentuckiana has been the leader in the fight to stop seizures, find a cure and overcome challenges created by epilepsy. We work everyday to educate, advocate, and support people with epilepsy and their families. This means working to make sure that all patients with epilepsy have the medications they need to try to live seizure-free lives.

On behalf of the 90,000 Kentuckians who suffer from epilepsy, we thank lawmakers for protecting critical access to care.

Deb McGrath is the Executive Director of the Epilepsy Foundation of Kentuckiana, which leads the fight to stop seizures, find a cure and overcome challenges created by epilepsy. 

Kentucky Voices for Health (KVH) believes preventing diseases before they ever happen should always be a healthcare priority.  An “immunization for life” strategy that encourages everyone, from children to seniors, to stay up to date on their vaccines is an easy and effective way of maintaining good health for life. 

In 2011, Kentucky moved to establish a vaccine entry requirement for children entering daycare and primary and secondary schools.  This important new requirement not only protects children and families from dangerous diseases but also opened up critical funding opportunities for the uninsured. 

Smart new health policies are important but we’re even happier to see their success in action.  KVH commends the Kentucky Department for Public Health’s Immunization Program for its recent recognition by the Centers for Disease Control and Prevention (CDC) for high immunization coverage levels for a childhood vaccination series.

This is a tremendous achievement for a state that has consistently ranked below the CDC’s recommended immunization rates. Kentucky’s childhood vaccination series coverage rate is now up to 80.6%, much higher than the national average of 73.1%. This is also a huge improvement from Kentucky’s 2007 child vaccination rate of only 63.3%.

This improvement is the product of years of work to increase Kentucky’s child immunization rates. Kentucky has made significant strides in recent years including changing the childhood immunization requirements in 2011 to align them more with CDC recommendations and creating the Vaccines for Children (VFC) Program to subsidize vaccines to low-income children.

Two of our top priorities at KVH are promoting children’s health and preventive care practices. We understand that one of the best ways to treat illness is to prevent it from ever happening in the first place, and that includes properly protecting all Kentuckians with safe and effective immunizations.

The Senate Health & Welfare Committee today heard testimony from numerous Kentucky health care providers about their many concerns and issues relating to Kentucky's new to Medicaid managed care environment.

Denying and delaying prior authorizations for medications, a lack of transparency in the system, inadequate reimbursement rates, denial of claims and complications with multiple formularies were all cited as issues that the three new Medicaid Managed Care Organizations (MCOs)
must address. These issues have one common goal in that they threaten to restrict patient access to quality care.  If not addressed, these issues have the long term potential to hurt patients and drive up healthcare costs.

The patient/provider relationship must be protected in this process and patient access cannot be jeopardized in efforts to conserve costs.

Do you have a personal story about the new managed care system? Let us know by calling the Kentucky Medicaid Managed Care Story Bank Hotline at 1-888-825-5592 or by filling out the following form on the KVH website: http://kyvoicesforhealth.com/form_view.php?form_id=7&from_cms=true

You can also educate your legislators on these important issues by calling the Kentucky Legislative Hotline at: 1-800-372-7181

The major health policy story of 2011 was Kentucky’s switch to Medicaid managed care—a move that will impact more than 540,000 Kentuckians.  But much more is on the way, and it will have a major impact on the rest of Kentuckians as soon we will begin seeing more reforms as a result of the Affordable Care Act (ACA).

As the ACA is implemented, it is important that patient access to care is not jeopardized. That is why Kentucky Voices for Health (KVH) has designated several focus areas to help guide the way policymakers, consumers and health care providers interact with the healthcare system.   These include consumer engagement in the development of new health exchanges (“a shopping mall for individual and small business health plans”), increasing access to preventative services, greater transparency in regards to coverage and costs, and most importantly, maintaining access to quality care.

The public must become more educated and engaged in order to take advantage of the new opportunities and greater amount of health-related information available to them. Standardizing the language used by plans and insurance companies is important for consumers to be smart, active purchasers of health coverage.  Individuals also need to be more aware of their personal health information and the care they are receiving in order to have a complete understanding of what they are paying for.  Health information technology is a tool that both patients and providers should use to improve care coordination and consumer engagement.

Individuals and employers are the real payors through the premiums paid to insurance companies.  That is why the Medical Loss Ratio (MLR) is so important to consumers by requiring that 80% of all premiums paid be used for medical services and quality improvement and not on marketing, administrative fees, commissions, and executive salaries.  It is important that the MLR be retained with strong consumer protections and rebates to ensure accountability to all of us who pay for care. 

Health reform will result in significant changes in the Commonwealth and will present many interesting challenges to our policymakers as they build health insurance exchanges that will make it easier for individuals to shop for coverage.  In addition, Medicaid will be expanded to cover additional Kentuckians with incomes up to 133% of the federal poverty level—making more than 250,000 additional Kentuckians eligible for Medicaid.  The bottom line is that for implementation to be successful in making coverage more affordable, it is important for all Kentuckians to be covered--including the currently estimated 604,000 Kentuckians who have no health insurance.

So health reform is not just a political endeavor, nor is it just about insurance companies, hospitals, clinicians. It is about me, you, our employers, and our communities.  I once heard the quote, “"Health starts where people live, learn, labor, play and pray." What are you doing to live a healthier lifestyle? How are you engaged in the care that you are receiving? Do you know the actual costs of the health care services you are receiving?  Is the service/procedure necessary for improving your quality of life?  These are all questions that we need to be asking. 

The concept of value-based health care purchasing is that buyers (you, me, and our employers) should hold providers and plans accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the money spent towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the delivery of high quality care.

Health reforms must promote fairness and provide security to families while allowing consumers and small businesses to buy affordable coverage and compare health plans. All stakeholders win in a value-based purchasing model with active consumer engagement.