[♪♪] GOOD EVENING.

WELCOME TO KENTUCKY TONIGHT.

I'M RENEE SHAW.

THANKS FOR JOINING US.

OUR TOPIC TONIGHT: KENTUCKY’S HEALTHCARE CHALLENGES.

WE’LL LOOK AT THE PLIGHT OF THE STATE’S RURAL HOSPITALS, INCLUDING STAFFING SHORTAGES; MEDICAL REIMBURSEMENTS, POSSIBLE RULES CHANGES TO MEDICAID ELIGIBILITY, AND IDEAS ON LOWERING PRESCRIPTION DRUG PRICES.

WE’LL TALK ABOUT ALL OF THAT, AND MORE, WITH OUR GUESTS, IN LEXINGTON: STATE SENATOR STEPHEN MEREDITH, A LEITCHFIELD REPUBLICAN AND CHAIR OF THE SENATE HEALTH SERVICES COMMITTEE; STATE SENATOR KAREN BERG, A LOUISVILLE DEMOCRAT, PHYSICIAN AND MEMBER OF THE SENATE HEALTH SERVICES COMMITTEE; VICKIE YATES BROWN GLISSON, HEALTH AND HEALTH INSURANCE LAWYER, AND CEO OF THE GLISSON GROUP; EMILY BEAUREGARD, EXECUTIVE DIRECTOR OF KENTUCKY VOICES FOR HEALTH; PATRICK PADGETT, EXECUTIVE VICE PRESIDENT OF THE KENTUCKY MEDICAL ASSOCIATION; AND DOCTOR STEPHEN HOUGHLAND, CHIEF MEDICAL OFFICER FOR THE KENTUCKY PRIMARY CARE ASSOCIATION.

SEND US YOUR QUESTIONS AND COMMENTS BY TWITTER AT K-Y TONIGHT K-E-T.

SEND AN EMAIL TO K-Y TONIGHT AT K-E-T DOT O-R-G. OR USE THE WEB FORM AT K-E-T DOT O-R-G SLASH K-Y TONIGHT.

OR YOU CAN CALL 1-800-494-7605.

WELCOME TO ALL OUR GUESTS.

FULL HOUSE ALL IN THE AT THE SAME TIME PLACE.

I LOVE THAT.

THANK YOU ALL FOR BEING HERE.

HOPE YOU HAD A GREAT SUMMER.

WE ARE FOCUSING ON LOTTEDS OF ISSUES LEADING UP TO THE NOVEMBER ELECTION AND HEALTHCARE WE KNOW IS A BIG CONCERN ON KENTUCKY VOTERS' MINDS.

I WANT TO ASK A VERY BROAD QUESTION TO GET US STARTED.

WHAT YOU PERCEIVE AS THE BIGGEST BARRIER TO HEALTHCARE ACCESS OR THE BIGGEST CHALLENGE TO THE INDUSTRY AND MR. CHAIRMAN, MEREDITH I WILL START WITH YOU, SENATOR.

>> THAT IS A BIG QUESTION.

THANK YOU.

I'VE THOUGHT WITH THE EXPANSION OF THE MEDICAID PROGRAM WHICH IS NEEDED FOR KENTUCKY AND WE HAVE HAVE BENEFITED FROM THAT FOLKS THINK THAT IS COMMENSURATE TO HEALTHCARE AND IT'S NOT PARTICULARLY IN RURAL COMMUNITIES WHILE COVID HAS BEEN DEVASTATING TO THE HEALTHCARE COMMUNITY AND TO OUR STATE IN GENERAL THE ISSUES WE ARE FACING ARE NOT NEW ISSUES.

COVID DID NOT CREATE THE ISSUES BUT IT PUSHED THEM OFF THE CLIFF AND MADE FOLKS AWARE THAT WE HAVE SOME TREMENDOUS CHALLENGES WITH FINANCIAL POSITION OF OUR RURAL HOSPITALS WITH THE LACK OF HEALTHCARE PROFESSIONALS IN OUR RURAL COMMUNITIES AND URBAN AREAS AS WELL.

AND WE ARE JUST DEEP COMPETITION WITH EACH OTHER, EACH OTHER BEING HEALTHCARE PROVIDERS FOR THOSE DESPERATE AND LIMITED HUMAN RESOURCES THAT JUST ARE NOT THERE.

AND TO TRY TO FILL THAT HOLE HAS CREATED INFLATIONARY PRESSURES ON ALL HEALTHCARE PROVIDERS WHETHER YOU ARE A HOSPITAL, NURSING HOME, PHYSICIAN PRACTICES THAT'S JUST UNREAL.

I THINK JUST ON THE HUMAN RESOURCES SIDE THAT WE'VE SEEN AN INCREASE OVER 300% IN THE COST OF STAFFING GROUPS THAT COME IN TO PROVIDE TEMPORARY COVERAGE.

AND THE INFLATION THAT WE'RE SEEING IN OUR ECONOMY IS TRIPLE IN THE HEALTHCARE ECONOMY.

SO IT'S EXERTING ALL KINDS OF PRESSURES.

>> Renee: WELL, SENATOR BERG, Dr. BERG DO YOU AGREE WITH WHAT MR. CHAIRMAN SAID DO YOU HAVE ANYTHING ELSE YOU WOULD ADD TO THAT?

>> ACTUALLY I DO AGREE AND I HAVE OTHER THINGS TO ADD AS WELL.

I AGREE THAT STAFFING AND THE INFLATIONARY PROCESSES AND WHAT IS HAPPENING BECAUSE WE DON'T HAVE ENOUGH HEALTHCARE PROVIDERS TO ACTUALLY OFFER SERVICES IN THE STATE, IS A HUGE ISSUE.

BUT IF YOU ARE GOING TO GO TO IN MY OPINION WHAT IS THE UNDERLYING CAUSE OF POOR HEALTH OUTCOMES IN THIS STATE IT'S POVERTY.

IT IS UNEQUIVOCALLY POVERTY.

SO AND WE SEE THAT IN RURAL PORTIONS OF THE STATE, IN URBAN PORTIONS OF THE STATE WE SEE SIMILAR OUTCOMES BASED ON SOCIOECONOMIC STATUS AND NEEDS THAT ARE JUST NOT BEING MET.

>> Renee: SO MS. GLISTON SON I WILL ASK YOU?

>> I THINK IT'S MORE EXACERBATED IN KENTUCKY BECAUSE WE HAVE MORE FOLKS LIVING IN RURAL AREAS.

50% OF OUR POPULATION LIVES IN A RURAL AREA ACROSS AMERICA IT'S 20%.

WE HAVE SO MANY INDIVIDUALS IMPACTED BY THIS.

YOU ALSO FIND SOME OF THOSE CHALLENGES ADDITIONAL CHALLENGES THAT CERTAINLY THE POVERTY ISSUE.

WE HAVE FOLKS LIVING IN POVERTY OR NEAR POVERTY.

SOME OF THE EXPENSES AROUND STAFFING AND SO FORTH OR THE LACK OF PHYSICIANS BUT YOU ALSO HAVE A GENERALLY IN THE RURAL AREAS YOU HAVE A SICKER POPULATION.

YOU HAVE AN AGED POPULATION UNFORTUNATELY MANY OF OUR AGED FOLKS LIVE IN RURAL AREAS.

AND THEN IF YOU HAVE THOSE ISSUES, THAT PUTS A BURDEN ON THE PHYSICIANS AND THE HOSPITALS THAT ARE THERE BECAUSE THEY ARE TAKING CARE OF FOLKS WITH LONG-TERM CHRONIC CONDITIONS AND KENTUCKY RANKS 49TH IN THE NATION ON LONG-TERM CHRONIC CONDITIONS.

THESE ARE EXPENSIVE CONDITIONS THAT HAVE TO BE TAKEN CARE OF.

SO I THINK WHEN YOU TAKE THE FACT THAT YOU GOT A SICKER POPULATION, THEIR AGED AND THEN ON TOP OF THAT WE HAVE A REIMBURSEMENT ISSUE THAT MANY OF THESE FOLKS ARE COVERED MOST ARE COVERED BY MEDICARE AND MEDICAID.

AND SO THE GOVERNMENT PAYERS DON'T PAY PROVIDERS ON THE BASIS OF COST.

I THINK MOST FOLKS GO TO THE DOCTOR AND HOSPITAL THEY DON'T THINK ABOUT THAT AND THEY DON'T REALIZE IT HAS NOTHING TO DO THIS IS WHAT IT COSTS TO TAKE CARE OF THAT PATIENT AND YOU HAVE FOLKS WITH LONG-TERM CARE CHRONIC CONDITIONS AND SO IF YOU HAVE INADEQUATE REIMBURSEMENT AND THOSE ARE DECISIONS BEING DIRECTED BY WASHINGTON AND WHAT THOSE PROGRAMS ARE GOING TO PAY.

UNFORTUNATELY THAT IS JUST THE WAY IT IS AND RURAL AMERICANS OVER 50% OF OUR CITIZENS ARE COVERED BY A GOVERNMENT PAYER PROGRAM AND THOSE REIMBURSEMENTS AREN'T BASED ON COST AND THERE'S VERY LITTLE COMMERCIAL THAT YOU CAN THEN USE TO OFFSET COMMERCIAL INSURANCE TO OFFSET THE COST.

YOU SHOULDN'T BE ABLE TO HAVE TO DO THAT BUT THAT IS THE WAY THE SYSTEM WAS PUT TOGETHER THROUGH THE YEARS.

>> Renee: MS. BEAUREGARD WE DON'T KNOW HOW MUCH IT COSTS WHEN WE GO TO THE STORE WE BUY MILK AND EGGS BUT AN X-RAY OR MEDICAL PROCEDURE WE DON'T KNOW THE MARKET VALUE.

>> THAT IS ABSOLUTELY TRUE FOR COMMERCIAL INSURANCE AS WELL.

BACK TO SOME OF THESE REAL THREATS TO KENTUCKY'S HEALTH AND TO RURAL HOSPITALS YOU KNOW, I COULDN'T AGREE MORE THAT POVERTY IS AN UNDERLYING CAUSE.

ONE OF OUR UNDERLYING CAUSES OF POOR HEALTH AND IT EXACERBATES POOR HEALTH OUTCOMES WHEN PEOPLE CANNOT MEET BASIC NEEDS, HOUSING, FOOD, CHILDCARE AND TRANSPORTATION THEY CAN'T FOCUS ON GETTING ACCESS TO CARE AND GETTING CARE THAT NEED TO BE HEALTHY OR STAY HEALTHY.

THAT IS SOMETHING THAT WE ALWAYS FOCUS ON WHEN WE'RE LOOKING AT POLICY.

IS THIS POLICY DESIGNED IN A WAY THAT WILL REDUCE THESE BARRIERS THAT WILL ALSO LOOK AT THE SOCIAL DETERMINANTS OF HEALTH AND HELP TO LEVEL THE PLAYING FIELD FOR KENTUCKIANS.

YOU KNOW RIGHT NOW, I THINK THE BIGGEST THREAT TO RURAL HOSPITALS IS THE NUMBER OF PEOPLE WHO ARE GOING THROUGH THE MEDICAID RENEWAL PROCESS, MEDICAID COVERAGE NOW HAVE HAD IT DURING THE PANDEMIC FOR THE PAST THREE YEARS AND NOW WE ARE UNWINDING THE PUBLIC HEALTH EMERGENCY WHICH IS NOT A SORT OF TERM THAT MOST PEOPLE ARE FAMILIAR WITH, WE'RE GOING THROUGH RENEWALS AND PEOPLE ARE BECOMING UNINSURED FOR THE FIRST TIME IN YEARS.

>> Renee: BECAUSE THEY ARE NOT FILLING OUT THE PAPERWORK OR GETTING NOTICES?

>> PAPERWORK REASONS, YES.

ABOUT ONE IN THREE KENTUCKIANS HAVE MEDICAID RURAL HOSPITALS RELY ON MEDICAID.

AND THAT IS HOW HOSPITALS CAN KEEP THEIR DOORS OPEN IN MANY PLACES.

AND WHEN YOU HAVE THAT MANY PEOPLE QUICKLY GOING THROUGH A RENEWAL PROCESS AND THE SYSTEM BEING OVERWHELMED AND PEOPLE NOT NECESSARILY KNOWING THAT IT'S THEIR TIME TO RENEW OR KNOWING WHAT THEY NEED TO SUBMIT AS DOCUMENTATION YOU END UP HAVING A LOT OF CHURN WHERE PEOPLE END UP LOSING HEALTH INSURANCE EVEN WHEN THEY ARE ELIGIBLE.

THAT IS A CONCERN THAT I HAVE.

AND YOU ADD TO THAT THE HOSPITALS RECENTLY WORKED WITH THE FEDERAL GOVERNMENT ACTUALLY AND STATE AND WERE ABLE TO DEVELOP A NEW PROGRAM CALLED THE HOSPITAL RATE IMPROVEMENT PROGRAM.

WHICH FOR HOSPITALS MEANS THAT THEY ARE NOW GETTING THE AVERAGE COMMERCIAL RATE FOR ALL MEDICAID REIMBURSEMENT INPATIENT AND OUTPATIENT.

IT WILL HURT EVEN MORE IF THEY HAVE PEOPLE LOSING MEDICAID COVERAGE AND BECOMING UNINSURED.

>> Renee: WE WANT TO TAKE THOSE IN DEPTH IN A BIT.

Mr. PADGETT WHO REPRESENTS THE KENTUCKY MEDICAL ASSOCIATION TELL US WHAT PHYSICIANS ARE CONCERNED ABOUT WHAT ARE THEIR GREATEST CHALLENGES?

>> MANY OF THE CHALLENGES THAT THEY'VE TALKED ABOUT HERE TONIGHT.

BUT I THINK I WOULD BOIL IT DOWN TO THERE ARE NOT ENOUGH WORKERS, PHYSICIAN, NURSES, THERE AREN'T ENOUGH WORKERS TO STAFF THE MEDICAL SYSTEM THAT WE HAVE.

BUT WHEN PEOPLE CAN GET IN TO SEE A PHYSICIAN OR ANOTHER PROVIDER, GETTING THEIR INSURANCE IF THEY HAVE INSURANCE GETTING THEIR INSURANCE TO ACTUALLY COVER WHAT THEY ARE THERE FOR AND IF THE INSURANCE DOES COVER WHAT THEY ARE THERE FOR OFTENTIMES THE INSURANCE WILL COME BACK LATER AND SAY YOU KNOW WE'RE NOT GOING TO COVER WHAT THAT WAS FOR.

YOU DIDN'T GET THIS OR DIDN'T GET THAT OR THIS DOESN'T LOOK RIGHT WE ARE GOING TO DENY THIS CARE AND THAT IS GETTING WORSE FOR PHYSICIANS, HOSPITALS AND PATIENTS ESPECIALLY AND THAT IS SOMETHING WE SEE A SPIKE IN.

>> Renee: IS THIS THE PRIOR AUTHORIZATION PROCESS?

>> THE PRIOR AUTHORIZATION AND OTHER ISSUES AS WELL BUT MAINLY PRIOR AUTHORIZATION.

>> Renee: Dr. HOUGHLAND THIS IS YOU AN MS. BEAUREGARD'S FIRST TIME ON THIS PROGRAM.

WELCOME.

YOU ARE VERY MUCH INVOLVED IN THIS HOW COULD YOU SEE THINGS?

>> IT'S NICE BEING THE LAST TO ANSWER THE QUESTION.

AND I APPRECIATE THAT.

THERE'S NOT A LOT TO ADD.

I THINK WHAT I WOULD SAY IS THAT WE CONSIDER ACCESS ALONG AT LEAST THREE PATHS.

ONE IS THAT THERE ARE ENOUGH PROVIDER TO BE ABLE TO PROVIDE THE SERVICE.

THERE'S ADEQUATE UNDERSTANDING AND OPPORTUNITY FOR THE PATIENTS THE CONSUMER TO BE ABLE TO GET IN TO SEE THE PROVIDER.

A PAYER OR THEY HAVE FINANCIAL MEANS TO BE ABLE TO DO THAT.

AND THEN THE OTHER PART OF ACCESS IS WHERE THEY HAVE FACTORS THAT MAKE IT MORE CHALLENGING FOR THEM, TRANSPORTATION, COMPETITION FOR THEIR FINANCIAL RESOURCES, FOR THEIR COPAY, COINSURANCE OR OTHER MEANS THAT THEY NEED THAT IS NOT PRESENT.

IT CONSUMES THEM AND THEY ARE NOT ABLE TO ACCESS THE CARE AT THAT POINT IN TIME.

AND I GUESS THE FOURTH POINT IS THE UNDERSTANDING THAT OF THE IMPORTANCE OF HEALTHCARE AND SOME SEGMENTS OF OUR COMMUNITIES IT'S MAYBE NOT AS WELL UNDERSTOOD.

AND THERE'S STIGMATIZATION ESPECIALLY FOR BEHAVIORAL HEALTH SERVICES.

AND HOW THAT HAS AN IMPACT TO CHRONIC CONDITIONS, CHRONIC MEDICAL PHYSICAL CONDITIONS AS WELL.

SO I'D SAY THAT IS THE FOURTH PILLAR OF ACCESS.

>> Renee: WE'LL GET TO SOME OF THOSE THINGS AND WE HAVE GOOD QUESTIONS FROM OUR VIEWERS.

I WANT TO GO BACK TO HOUSE BILL 75 THAT WAS PASSED IN THE 2023 SESSION THIS DEALT WITH WHAT WAS CALLED H RIP WHAT SHE MENTIONED MS. BEAUREGARD EXPANDS THE MEDICAID HOSPITAL RATE IMPROVEMENT PROGRAM.

THIS WAS REALLY IMPORTANT TO HELP RURAL HOSPITALS KEEP AFLOAT AND WE SPOKE WITH DONNA VAN BLACKBURN THE C.E.O.

OF PIKEVILLE MEDICAL CENTER AND SAID THAT WAS A BLESSING TO THEM BECAUSE OTHERWISE THEY MAY HAVE BEEN FACING REALLY DIFFICULT FINANCIAL HARDSHIPS.

CAN YOU PUT THAT INTO CONTEXT WHY THAT IS SO IMPORTANT?

>> WELL, MOST CERTAINLY.

I RETIRED FROM THE HOSPITAL INDUSTRY IN 2013.

AT THAT TIME THE AVERAGE PROFIT MARGIN FOR HOSPITALS IS ABOUT 2%.

AND HAS DECLINED EVER SINCE THEN.

I THINK IN 2019 BEFORE COVID THE LOSS WAS 3.2%.

SO WE'RE SEEING MORE AND MORE HOSPITALS PARTICULARLY RURAL HOSPITALS WHO HAVE A HEAVY RELIANCE ON MEDICARE AND MEDICAID SUFFERING FROM THAT POOR REIMBURSEMENT SOMETHING HAS TO BE DONE.

WE HAVE WHAT WE CONSIDER 63 RURAL HOSPITALS IN KENTUCKY IN ALMOST A THIRD OF THOSE HAVE FINANCIAL METRICS THAT SUGGEST THEY MAY NOT BE AROUND WITHOUT ASSISTANCE.

WE PASSED LEGISLATION IN 2019 THE H RIP THE FIRST TIME FOR INPATIENT SERVICES IN THIS LAST TIME 2022 WE DID THE OUTPATIENT SERVICES.

BUT IT'S LIFELINE FOR HOSPITALS.

WHEN WE DID THE INPATIENT SIDE IT WAS BEFORE COVID AND IT REALLY I THINK STABILIZED THE HOSPITALS FINANCIAL POSITION.

DIDN'T LIFT THEM UP TO WHERE THEY WANTED TO BE BUT THEN COVID HIT AND LOST REVENUE AND PATIENT VOLUMES WE HAVE NOT RECOVERED FROM.

IF WE DIDN'T HAVE THE H RIP PROGRAM FOR INPATIENT AND OUTPATIENT I'M CONFIDENT YOU WOULD SEE RURAL HOSPITALS CLOSE IN KENTUCKY.

>> Renee: HOW MUCH DID THAT COST THE STATE?

>> NOTHING.

NOTHING.

IT IS AN ASSESSMENT ON THE HOSPITALS ON THEIR REVENUE IT IS A MATCHING PROGRAM.

COSTS ARE NOTHING.

WHICH ALWAYS BEWILLEDDERS ME THESE SOLUTIONS ARE OUT THERE THAT WE DON'T PURSUE THEM LIKE WE SHOULD.

>> Renee: YOU AGREE, Dr. BERG, SENATOR BERG WITH THAT?

I DON'T KNOW WHETHER TO CALL YOU DOCTOR OR SENATOR, MR. CHAIRMAN OR SENATOR I WILL MIX IT UP THROUGHOUT THE EVENING?

>> I TOTALLY AGREE THIS WAS EXCELLENT LEGISLATION WE NEEDED TO DO THIS.

PEOPLE HAVE TO UNDERSTAND HOSPITALS ARE NOT GETTING PAID WHAT IT COSTS THEM TO GIVE THE SERVICES.

AND SO THAT IS AN UNSUSTAINABLE BUSINESS MODEL IT IS NOT POSSIBLE TO STAY BE ABLE TO STAY ALIVE IF YOU'RE SPENDING MORE MONEY THAN YOU ARE GETTING.

SO THESE TYPE OF THINGS ARE ABSOLUTELY ESSENTIAL.

AND WITHOUT YOUR RURAL HOSPITALS, I MEAN WE ALREADY HAVE SUCH A LIMIT ON RURAL PROVIDERS.

ONCE YOU LOSE THAT HOSPITAL YOU LOSE THAT ENTIRE HEALTHCARE COMMUNITY.

BECAUSE THEY NEED THE SUPPORT, YOUR PHYSICIANS YOUR NURSE PRACTITIONERS YOUR NURSES THEY NEED THE SUPPORT OF A HOSPITAL TO BE ABLE TO ULTIMATELY PROVIDE SERVICES.

WITHOUT THEM, YOU HAVE NO HEALTHCARE.

>> WE KNOW THAT FOUR HOSPITALS CLOSED IN THE LAST 16 YEARS IN KENTUCKY TO YOUR POINT SENATOR MEREDITH 40% OF OUR HOSPITALS IN KENTUCKY ARE AT RISK OF CLOSING NOW.

AND FOR PHYSICIANS WE KNOW THAT THERE ARE TWO-THIRDS OF OUR COUNTIES ARE LACKING IN PRIMARY CARE SERVICES.

I MEAN WHEN I START LOOKING AT THOSE NUMBERS IT'S JUST STARTLING.

AND IT'S ALMOST GOTTEN TO THE POINT IT'S ALMOST HIGH-RISK TO LIVE IN A RURAL AREA IN KENTUCKY.

IT'S THAT SERIOUS, I THINK.

>> Renee: AND PHYSICIANS ARE ALSO LOOKING AT A DECREASE IN MEDICARE, TALK TO US ABOUT THAT AND Mr. PADGETT AS WELL?

>> IT'S THEY'VE HAD A 26% DECREASE SINCE 2001.

THIS YEAR IT WILL BE A PROBABLY SOMEWHERE AROUND 2.3% I THINK NEXT YEAR IT'S 1.25%.

INSTEAD OF IN THE MEANTIME, EVERYTHING'S GONE UP.

>> Renee: WHY IS IT DECREASING AND NOT KEEPING UP WITH INFLATION?

>> YOU HAVE EQUIPMENT THE IT SYSTEMS ALONE TO BE ABLE TO QUALIFY TO GET PAID BY THE PROVIDERS WHETHER IT IS A HOSPITAL OR A PHYSICIAN'S OFFICE, THESE THINGS ARE ENORMOUSLY EXPENSIVE AND YOU HAVE EQUIPMENT AND YOU'VE GOT STAFFING AND INFRASTRUCTURE AND OFFICES.

BUT INSTEAD, TO THIS POINT ABOUT NOT BEING ABLE TO REMOTELY HIT COST, THEY ARE CONTINUING TO DECREASE THESE PAYMENTS SO PHYSICIANS I THINK ARE AGING OUT SAYING I'M GOING TO RETIRE I CANNOT AFFORD TO KEEP THE OFFICE OPEN.

NEW PHYSICIANS AND I THINK SENATOR MEREDITH CAN TALK ABOUT THIS NEW PHYSICIANS ARE MAKING DECISIONS TO SAY I CAN'T AFFORD TO GO INTO A RURAL AREA BECAUSE I CAN'T HE AFFORD TO RUN AN OFFICE THERE.

AND TO BE ABLE TO MAINTAIN AN OFFICE.

IT'S IMPACTING THAT AND MAKING THAT TWO-THIRDS OF OUR COUNTIES DON'T HAVE ENOUGH PRIMARY CARE COVERAGE IT'S JUST EXACERBATING THAT PROBLEM.

>> Renee: WHAT DOES THE PRIMARY CARE ASSOCIATION SAY ABOUT THIS?

>> IT'S CERTAINLY TOP OF MIND.

THERE IS A PHENOMENON WE HAVE BEEN SEEING THAT WHILE ACKNOWLEDGE THAT MANY COMMUNITIES, HOSPITALS ARE BEING CHALLENGED, MANY ARE ALSO ACTIVELY RECRUITING AND BUYING PHYSICIAN PRACTICES.

AND SO FEWER PHYSICIANS ARE IN INDEPENDENT SETTINGS OR WORKING FOR COMMUNITY MENTAL HEALTH CENTERS OR RURAL HEALTH CLINICS WHICH DEFENSE BUDGET AN ALTERNATIVE FOR WORKING ALONE VERSUS BEING EMPLOYED BY THE SYSTEM NOT AT THE SYSTEMS ARE BAD IT IS AN ALTERNATIVE.

AND IT CAN EXACERBATE SOME OF THE PROBLEM WITHIN COMMUNITIES AND ONE THING THAT WE HAVEN'T REALLY FOUND A GOOD ANSWER FOR IN MY OPINION IS HOW MANY PATIENTS A PARTICULAR PHYSICIAN OR A GROUP IS TAKING CARE OF.

WE KNOW BY INSURER IN GENERAL HOW MANY MAYBE ATTRIBUTED TO AN INSURER.

BUT WE DON'T KNOW IN TOTAL.

AND MEDICAID WE HAVE BETTER NUMBERS AND THERE'S CERTAIN REQUIREMENTS TO MEET A NUMBER OF PATIENTS PER FTE PHYSICIAN BUT IN THE REST.

>> Renee: FTE.

>> FULL-TIME EQUIVALENT.

THERE IS NOT REALLY A COMPARABLE MEASURE WITH OTHER INSURERS THAT'S IN CONTRACT AN EXPECTATION.

THE COMMUNITY GENERALLY SAYS THAT A PHYSICIAN SHOULD ONLY TAKE CARE OF A CERTAIN NUMBER OF PATIENTS BUT THERE'S NOT A GOOD UNDERSTANDING.

WE HAVE A REAL MISMATCH BETWEEN UNDERSTANDING WHAT THE WORKFORCE LOOKS LIKE AND WHAT THE PATIENTS WITHIN A PARTICULAR AREA LOOK LIKE.

AND I THINK THERE'S REAL OPPORTUNITIES IF WE CAN GET A BETTER GAUGE OF WHAT THE IMPANELMENT OF A PARTICULAR PROVIDER IS.

>> Renee: DATA IS IMPORTANT HERE.

>> ABSOLUTELY IS IMPORTANT.

AND RIGHT NOW, WE HAVE DIFFERENT LICENSURE BOARDS OPERATING DIFFERENTLY SILOED WHERE THE INFORMATION THAT THEY COLLECT FROM THE PARTICULAR PROVIDERS THAT THEY LICENSE, CAN LOOK DIFFERENT FROM ONE BOARD TO THE NEXT.

AND NONE OF THEM ARE COLLECTING UNIFORM OR COMPREHENSIVE INFORMATION.

AND SO YOU CAN HAVE A PROVIDER FILL OUT THIS INFORMATION WITH THEIR HOME ADDRESS, EVEN IF THEY WORK AT A CLINIC OR A HOSPITAL IN ANOTHER COUNTY OR MAYBE THEY HAVE MULTIPLE LOCATIONS, YOU CAN HAVE PEOPLE WHO ARE LICENSED WHO ARE NOT WORKING IN CLINICAL PRACTICE OR PART-TIME OR RETIRED AND THEY ARE ALL GETTING COUNTED RIGHT NOW AS BEING A LICENSED PROVIDER THAT IS AVAILABLE TO SEE PATIENTS.

AND SO WE DON'T HAVE A GOOD HANDLE ON WHAT OUR REAL WORKFORCE IS WHAT THE CAPACITY IS, WHAT THE NEEDS ARE, WHERE THE GAPS ARE.

SO THAT WE CAN BE MORE INFORMED AND TARGETED IN OUR POLICY APPROACHES.

I THINK THIS ALSO REALLY IS AN ISSUE FOR NETWORK ADEQUACY AS WELL.

THEY ARE KIND OF TWO PIECES OF THE SAME PUZZLE.

WE NEED AN ADEQUATE WORKFORCE AND WE NEED TO KNOW THAT INSURERS HAVE ADEQUATE NETWORKS TO SERVE PATIENTS AND WHEN SOMEONE IS SEEKING CARE AND OF COURSE THEY ARE GOING TO WANT CARE THAT IS IN NETWORK NOT OUT-OF-NETWORK WHERE YOU ARE GOING TO BE PAYING MORE OUT OF POCKET.

SO YOU NEED TO BE ABLE TO FIND YOUR IN NETWORK PROVIDERS AND HAVE ACCESS WHEN STEVE WAS TALKING ABOUT THE DIFFERENT ACCESS ONE IS BEING ABLE TO ACTUALLY FIND A PROVIDER IN YOUR COMMUNITY, WHO IS AVAILABLE WITHIN A REASONABLE TIME-FRAME AND TAKES YOUR INSURANCE.

AND THAT'S ANOTHER SIDE OF THAT COIN THE WORKFORCE COIN.

>> Renee: Mr. PADGETT?

>> I AGREE.

I THINK ANYTIME THAT A PATIENT IS GOING TO GO SEE ANY TYPE OF PROVIDER WHETHER IT IS A SURGEON, PRIMARY CARE PHYSICIAN, A PHYSICAL THERAPIST OR ANYONE ELSE AND IT TAKES THREE MONTHS, SIX MONTHS, EIGHT MONTHS TO GET IN, THEY ARE EXPERIENCING THE SHORTAGE WE ARE TALKING ABOUT RIGHT NOW.

AND I DON'T THINK IT'S JUST THAT THE PROVIDER LEVEL BUT CERTAINLY WE HAVE A SHORTAGE OF PROVIDERS.

AND I WOULD GO BACK TO WHAT VICKY WAS SAYING EARLIER IT IS VERY DIFFICULT RIGHT NOW FOR PHYSICIANS BUT AGAIN I THINK ANY PROVIDER, TO BE IN PRIVATE PRACTICE.

IT IS JUST REALLY, REALLY DIFFICULT BECAUSE THE PAYMENTS FROM WHETHER IT'S MEDICARE, MEDICAID, COMMERCIAL INSURANCE JUST ARE NOT KEEPING UP.

THEY ARE BECOMING EMPLOYED.

AND ACCORDING TO THE INFORMATION THAT WE HAVE AND THAT WE'VE GATHERED FROM OUR MEMBERS, ANYWHERE BETWEEN 60, 65% OF PHYSICIANS ARE NOW EMPLOYED.

THEY DON'T OWN THEIR OWN PRACTICE THEY DON'T RUN THEIR OWN PRACTICE.

THAT IS VERY DIFFERENT THAN SAY 10 YEARS AGO WHERE THOSE NUMBERS WERE REVERSED IT WAS 40% WERE EMPLOYED.

SO THE HEALTHCARE SITUATION IN KENTUCKY HAS CHANGED A LOT.

BUT IT'S CHANGED A LOT FOR A LOT OF THE REASONS WE'VE TALKED ABOUT.

>> Renee: THIS QUESTION FROM ROBERT COMING IN RUSSELL COUNTY, WHY DO INSURANCE COMPANIES SEEM TO HAVE A BIGGER INFLUENCE THAN DOCTORS IN TERMS OF PATIENT'S CARE AND OPTIONS?

>> THAT IS A REALLY GREAT QUESTION.

>> Renee: BECAUSE THEY DO.

BUT WHY?

GO AHEAD SENATOR BERG.

>> I CAN TELL YOU WHY I THINK THEY DO.

AND IT IS THE SAME THING NOW HAPPENING WITH OUR PHARMACY BENEFIT MANAGERS BECAUSE THEY GET TO DECIDE WHAT IS GOING TO BE COVERED AND WHAT ISN'T GOING TO BE COVERED.

AND THERE'S NO TO TRY TO GET RECOURSE TO THAT IS SO OVERWHELMINGLY DIFFICULT, THAT PHYSICIANS DON'T HAVE THE TIME, THE ENERGY THE WHEREWITHAL TO SPEND I'VE HEARD DATA THE AVERAGE PHYSICIAN PRACTICE IN THE UNITED STATES IF YOU TAKE ALL COMERS TOGETHER WILL SPEND $100,000 ON BILLING ON BILLING ALONE.

IMAGINE?

WHAT TYPE OF RESOURCES YOU'RE EXPENDING TRYING TO GET INSURANCE COMPANIES TO ACTUALLY PAY FOR WHAT THEY'RE SUPPOSED TO COVER.

IT IS EXHAUSTING.

IT IS EXPENSIVE.

IT IS TIME CONSUMING.

AND IT IS MONEY THAT SHOULD BE BEING SPENT ON DIRECT PATIENT CARE.

PEOPLE NEED TO UNDERSTAND WE HAVE BILLIONS OF DOLLARS IN OUR HEALTHCARE SYSTEM.

WHAT WE NEED TO BE DOING IS MAKING SURE THAT MONEY IS GOING TO DIRECT PATIENT CARE.

NOT TO THE PEOPLE WHOSE JOB IT IS TO OVERSEE WHAT YOUR INSURANCE IS GOING TO PAY OR WHETHER OR NOT THE PHARMACY IS GOING TO ACTUALLY FILL A PRESCRIPTION THAT YOUR DOCTOR WROTE.

BECAUSE NOW ALL OF A SUDDEN THEY GET TO DECIDE IF THAT IS THE APPROPRIATE MEDICATION FOR YOU OR NOT.

JUMP IN.

JUMP IN.

>> I WAS GOING TO SAY WITH INSURANCE COMPANIES THEY CALL THEMSELVES MANAGE CARE COMPANIES.

BUT THEY ARE NOT MANAGE CARE THEY ARE NOT MANAGING THE CARE OF THE PATIENT.

THAT IS WHAT THE PROVIDERS ARE DOING.

THEY ARE MONEY MANAGERS.

THEY MANAGE THE MONEY WITHIN THE SYSTEM AND THEY MANAGE THAT MONEY AS TO HOW IT'S SPENT IN ANY PARTICULAR 365-DAY PERIOD RATHER THAN LOOKING AT A PATIENT THAT MIGHT NEED A MEDICATION OR PROCEDURE THAT WILL HELP THEM FOR YEARS TO COME.

AND TO ME THAT'S NOT MANAGED CARE.

THEY ARE MANAGING MONEY IN A ONE-YEAR TIME THAT IS WHAT THEY DO.

>> IT'S NOT ABOUT THE MONEY IT'S ABOUT THE MONEY.

YES IT IS.

AND TO SENATOR BERG'S POINT WE SPEND ALMOST 30 CENTS OF EVERY DOLLAR IN HEALTHCARE JUST ON ADMINISTRATION THAT'S DOUBLE WHAT OTHER INDUSTRIALIZED NATIONS ARE DOING FOR THE UNITED STATES WE ARE SPENDING ABOUT $13,000 PER CAPITA ON HEALTHCARE.

THE NEXT CLOSEST IS GERMANY AND THEY ARE SPENDING $7,000.

WHY ARE WE SO RADICALLY DIFFERENT AND PART IS THE OVERHEAD WE ARE HAVING TO DEAL WITH LIKE OUR MANAGED CARE PROGRAMS IN KENTUCKY I FILED LEGISLATION FOR FOUR YEARS TO REDUCE THE NUMBER OF MANAGED CARE ORGANIZATIONS TO HANDLE OUR MEDICAID PROGRAM WE HAVE SIX WE DON'T NEED SIX.

WE'VE AGREED TO SETTLE FOR THREE AND THE EXCUSE IT'S TOO MUCH RISK.

CALIFORNIA -- >> Renee: TOO MUCH RISK OF WHAT?

>> TO THE INSURANCE COMPANIES WHEN WE ADOPTED MANAGED CARE WE HAD ONE OF THE COMPANIES LEAVE AND CREATED CHAOS N CALIFORNIA HAD MANAGED CARE FOR A LONGTIME AS WELL THEY HAVE 26 INSURANCE COMPANIES THAT HANDLE THE POPULATION.

THAT IS 1.6 BILLION PER CAPITA OF PEOPLE.

IN KENTUCKY WE'RE AT 750,000 PER CAPITA.

THERE'S ROOM FOR ADDITIONAL RISK AND IF YOU TALK TO THE MCO'S THEY WOULD SAY WOULD YOU WELCOME MCO'S AND THEY SAY YES, THEY WOULD.

BUT THE BUREAUCRATIC BURDEN PLACED ON HEALTHCARE PROVIDERS IS STAGGERING.

WE HEARD TESTIMONY FROM A SMALL MENTAL HEALTH PROVIDER THAT SERVICE A FIVE COUNTY AREA SHE HAD THREE, FOUR EMPLOYEES HAD AN AUDIT BY ONE OF THE ORGANIZATIONS AND AFTER THE AUDIT THEY SAID NO PROBLEMS COUPLE WEEKS LATER SHE HAD ANOTHER AUDIT AND THEY SAID YOU OWE US $25,000 AND SHE APPEALED IT AND A YEAR LATER IT HAS NOT BEEN RESOLVED FOR A SMALL PROVIDER LIKE THAT THAT'S DEVASTATING.

IT CANNOT SUSTAIN ITSELF.

AND IT'S CREATING A CRISIS ON THE NATIONAL LEVEL.

WE CAN'T BE COMPETITIVE IF WE CAN'T GET CONTROL OF OUR HEALTHCARE COSTS.

AND MOST OBVIOUS PLACE TO DO THAT IS AT THE BUREAUCRACY, FIRST.

>> DO YOU AGREE?

>> THERE IS A LOT OF LAYERS IN THE SYSTEM AND I WOULD SUGGEST THAT IF WE SET OUT TODAY TO CREATE A SYSTEM IT WOULD LOOK DIFFERENT THAN IT DOES RIGHT NOW.

THERE IS A LOT OF WAYS TO TRY TO ATTACK THAT.

FOCUSING ON SHIFTING FROM BEING ACUTE CARE PARADIGM TO MORE PREVENTION AND HEALTH AS OPPOSED TO HEALTHCARE OR IN ADDITION TO HEALTHCARE.

SOMETHING WE NEED TO DO NOW.

THE PROBLEM IS THAT IS AN INVESTMENT.

SO IT'S GOING TO TAKE SOMETIME TO GET TO THAT POINT AND WE NEED TO FIND OUR BRIDGE TO THAT.

INVESTMENT IN HIGH QUALITY LOWER COST OUTPATIENT SERVICES IS HARD TO ARGUE AGAINST.

AND EFFECTIVE PRIMARY CARE AND OTHER SERVICES TO HELP PROMOTE INDIVIDUALS GETTING INTO PRIMARY CARE AND BEHAVIORAL SUBSTANCE USE DISORDER TREATMENT OFTEN FITS INTO THAT PARADIGM.

WE HAVE A LOT OF INVESTMENT IN HIGH COST SERVICES.

PEOPLE NEED THEM.

BUT WE ALSO COULD ADDRESS THINGS GET UPSTREAM A BIT AND HAVE A VERY DIFFERENT OUTCOME OVER THE NEXT DECADE, TWO DECADES.

THE OTHER THING I WOULD ADD IS ONE OF THE TRENDS WE'VE BEEN SEEING IS THAT'S HAD AN IMPACT ON PRIMARY CARE SERVICES, IS PHYSICIANS HAVE BEEN SHIFTING TO SPECIALTY CARE FOR MY ENTIRE PROFESSIONAL CAREER NOW OVER 20 YEARS.

WHEN I FIRST STARTED I AM AN INTERNNIST I STARTED HALF OF INTERNAL MEDICINE GRADUATES WOULD GO INTO PRIMARY CARE AND HALF INTO SPECIALTY CARE.

FAMILY MEDICINE IS SHIFTING TO SPECIALLY CARE.

PART OF THE SOLUTION WAS ADVANCED NURSE PRACTITIONERS, PHYSICIANS ASSISTANTS TO HELP WITH THAT.

NOW WE'RE SEEING NO SHIFTING.

AND TO SPECIALTY SERVICE HOSPITAL BASED SERVICES SPECIALTY SERVICES ON THE OUTPATIENT SIDE AS WELL AND FEWER ARE DOING PRIMARY CARE SERVICES.

WE'VE ACTUALLY MAGNIFIED THAT GAP AND PART OF IS DUE TO WORK LIFE BALANCE.

PART IS DUE TO SALARY AND COMPENSATION.

AND SOME OF THAT IS BECAUSE OF THE EMPLOY EMODEL WHERE SPECIALISTS ARE GENERALLY REIMBURSED AT A HIGHER RATE, PAID HIGHER NOT JUST REIMBURSED BY INSURERS THAT IS NOT REALLY THE CASE.

IT'S THAT THEIR SALARY THEY COMMAND FROM THE EMPLOYER IS HIGHER.

SO THEY IT'S MORE ATTRACTIVE FOR PEOPLE TO ENTER THOSE FIELDS THAN PRIMARY CARE FIELDS PEDIATRICS, FAMILY MEDICINE INTERNAL MEDICINE.

>> I WANTED TO GO BACK TO WHAT YOU WERE SAYING ABOUT THE DIFFERENCES BETWEEN SICK CARE AND WELL CARE, PREVENTION, HOW WE'RE SPENDING OUR MONEY AND WHAT VALUE WE'RE GETTING FROM IT AND HOW WE GET UPSTREAM.

AND I THINK ONE WAY THAT WE CAN DO THIS AND THAT MANY, MANY STATES ARE ALREADY LOOKING AT THIS IS BY HAVING MORE DATA AND ALL PAYER CLAIMS DATABASE WHICH IS NOT A HOUSEHOLD TERM BUT NOTHING SEXY THERE BUT HAVING THE PAYERS ALL OF THESE DIFFERENT PAYERS WHETHER IT'S GOVERNMENT, COMMERCIAL, PRIVATE INSURANCE, HAVING THE SAME UNIFORM DATA CLAIMS DATA GOING INTO ONE CENTRAL REPOSITORY A DATABASE IN WHICH YOU CAN COMPARE APPLES TO APPLES, DIFFERENT REGIONS OF THE STATE IN TERMS OF HEALTH OUTCOMES DISPARITIES, CARE GAPS WHAT DOES THE WORKFORCE LOOK LIKE, WHERE IS THERE OVERUTILIZATION, UNDERUTILIZATION WE SOMETIMES USE THE TERM LOW VALUE CARE YOU ARE SPENDING MONEY ON SOMETHING THAT IS NOT PRODUCING BETTER HEALTH OUTCOMES AND IS NOT NECESSARILY GOOD FOR THE PATIENT.

SOMETIMES CREATES PATIENT HARM.

WE CAN USE THE DATABASE LIKE THAT TO MAKE MUCH MORE INFORMED AND MORE TARGETED POLICY DECISIONS.

AND I THINK WHENEVER YOU GET TO RURAL HOSPITALS IN PARTICULAR, YOU KNOW, THE FINANCIAL VARIETY OF RUBL HOSPITALS BEING ABLE TO LOOK AT PAYER MIX, RESOURCES, THE DIFFERENT REVENUES THAT THAT HOSPITALS HAVE AND WHAT THE COSTS ARE FOR RURAL HOSPITALS, TO REALLY HONE IN ON WHERE THE GREATEST NEED IS AND CREATE AGAIN THOSE TARGETED INTERVENTIONS AND MAKE SURE THAT WE ARE INVESTING IN THE RIGHT THINGS.

>> Renee: A COUPLE OF COMMENTS COMING IN FROM OUR VIEWERS.

INTERESTED IN THIS TOPIC AND WE APPRECIATE Y'ALL'S ATTENTION.

FROM PATRICIA REGISTERED NURSE IN FAYETTE COUNTY, QUOTE IF HOSPITALS RESPECT'S MAKING ENOUGH MONEY HOW ARE INSTITUTIONS LIKE U.K., ST. JOSEPH AND CENTRAL BAPTIST ABLE TO BUY UP SMALLER HOSPITALS IN RURAL AREAS?

>> THAT A FAIR QUESTION.

I THINK THAT PEOPLE DON'T UNDERSTAND THE DYNAMICS OF THE HEALTHCARE SYSTEM.

THE RURAL HOSPITALS ARE SUFFERING THE MOST AND IF YOU LOOK AT THE PAYMENT PRACTICES THEY DISCRIMINATE AGAINST RURAL HOSPITALS.

I THINK THE DISCUSSION IS INTERESTING WHEN I BECAME THE C.E.O.

IN 1983, SAME TIME WE STARTED THE PAYMENT SYSTEM REDUCING REIMBURSEMENT FOR HOSPITALS AND I REALIZED WE HAD TO GROW OUR REVENUE FASTER THAN THE REIMBURSEMENT CUTS WERE COMING I HAD SEVEN DOCTORS ON MY MEDICAL STAFF AT THAT TIME AND I TOLD THE DOCTORS WE HAVE TO BRING MORE PEOPLE IN.

THEY DIDN'T LIKE THE IDEA BECAUSE THEY SAW IT AS COMPETITION BUT BY THE GRACE OF GOD AND SOME MORE LUCK THAN ANYTHING WE DID RECRUIT BUT WHAT I FOUND WAS WHEN I WAS TRYING TO BRING IN PHYSICIANS THE NUMBER ONE QUESTION THEY HAD IS WHAT PERCENTAGE OF THE POPULATION IS MEDICAID.

AND IT WAS ALMOST IMPOSSIBLE TO OVERCOME.

WHAT WE DID IN THE LATE 90s, EARLY 2000'S WE STARTED A MEDICAL FOUNDATION AND TOLD PHYSICIANS IF YOU WILL COME HERE WE WILL PAY THE SALARY AND IF YOU ARE PRODUCTIVE PHYSICIAN WE'LL PAY YOU A BONUS.

WE WENT FROM SEVEN PHYSICIANS TO 34 THIS IS 26,000 POPULATION COMMUNITY SERVICES 100,000.

BUT THOSE SEVEN DOCTORS WERE ONE GENERAL SURGEON ONE PEDIATRICIAN AND THE REST WERE FAMILY MEDICINE.

THE RESULT OF THE MEDICAL FOUNDATION 34 DOCTORS HAVE PULMONARY MEDICINE, EAR NOSE AND THROAT, FIVE PEDIATRICIANS WHO ORTHOPAEDIC SURGEONS AND OBGYN A SERVICE YOU DON'T FIND IN MOST RULE COMMUNITIES BECAUSE YOU LOSE MONEY OR PHYSICIAN PRACTICES BUT THE HOSPITAL AVERAGE 6.5% RETURN THREE TIMES WHAT THE NATIONAL AVERAGE WAS AT THAT TIME.

SO IT CAN WORK IF PHYSICIANS ARE PAID FAIRLY.

PEOPLE WANT TO COME TO RURAL COMMUNITIES THEY LIKE THE QUALITY OF LIFE THAT WE CAN OFFER.

BUT WHY WOULD ANYBODY CHOOSE AND I POSED THIS QUESTION TO THE CABINET WHY WOULD ANYONE CHOOSE TO COME TO A RURAL COMMUNITY KNOWING YOU WILL MAKE 30% LESS THAN THE URBAN COUNTERPARTS.

SOME PEOPLE HAVE A PASSION FOR THAT.

BUT THEY SHOULDN'T BE PENALIZED BECAUSE THEY HAVE A PASSION AND A MISSION FOR IT.

IT GOES BACK TO THE DATA.

WE KNOW WHAT THE SITUATION IS.

I'VE KNOWN IT SINCE THE 70s BUT WE DON'T ACT UPON IT AND THAT IS MY CONCERN.

IS WE'RE GOING TO HAVE THE DATA AND WHAT ARE WE GOING TO DO WITH IT.

SET POLICY WE NEED ACTION AND WE'RE NOT SEEING ACTION.

>> Renee: GO AHEAD.

>> I WOULD ADD A COUPLE THINGS WITH THE DATA, TOO, IS THAT WE HAVE TO MAKE SURE IF WE HAVE AN ALL CLAIM ALL PAYERS CLAIMS DATABASE THAT IS CLAIMS DATA.

CLAIMS DATA IS ALL GEARED TOWARD A CODE TO GET PAID.

SO I THINK IT'S VERY IMPORTANT TO BE REALISTIC ABOUT WHAT YOU ARE GOING TO GET WHICH CLAIMS DATA IS VERY LIMITED AND IF YOU REALLY WANT A LOT MORE ROBUST DATA AND THE INFORMATION THAT YOU CAN GET FROM DATA IT'S GOING TO HAVE TO GO BEYOND THE CLAIMS THAT IS ONE POINT.

THE OTHER THING IS I THINK WE WERE TALKING ABOUT THE IMPACT OF POVERTY IN THE RURAL AREAS, AND HOW YOU KEEP THESE RURAL HOSPITALS AFLOAT AND ONE OF THE BIG PROGRAMS THAT HAS BEEN OUT THERE THAT ALLOWED RURAL HOSPITALS SAFETY NET HOSPITALS TO STAY AFLOAT IS THE 340B PRICING PROGRAM.

I WOULD BRING THAT UP THAT THAT NEEDS TO BE LOOKED AT BECAUSE IT ALLOWS A SAFETY NET HOSPITAL OR A RURAL HOSPITAL TO BUY THEIR DRUGS AT A LOWER COST AND THEN THEY CAN PASS THAT SAVINGS ON TO PATIENTS THAT ARE LIVING IN POVERTY.

THEY GET SOME OF THESE ONCOLOGY DRUGS COULD BE THE PRICE OF A HOUSE AND THEY CAN THEM AT FREE TO LITTLE OR NO COST IT IS AN IMPORTANT PROGRAM FOR THE HOSPITAL AND THE PATIENT IT ALLOWS THE HOSPITAL TO CHARGE THE LARGER THEY GET THE UPSIDE THEY CAN CHARGE A HIGHER RATE.

IT HELPS THEM UNDER GURD ALL OF THE LOSSES THAT THEY HAVE FROM REIMBURSEMENTS THROUGH MEDICARE AND METHOD MEDICAID.

>> IT IS IN JEOPARDY, THE FEDERAL GOVERNMENT HAS BEEN TRYING TO DO AWAY WITH 340B PRICING FOR SOMETIME.

MY ONLY THING I'M TRYING TO POINT OUT IS HAS UNDER GERTED AND REPRESENTATIVE RURAL HOSPITALS AFLOAT MANY OF OUR SAFETY NET HOSPITALS IT'S FOR NONPROFIT HOSPITALS PROVIDING INDIGENT CARE IF THAT GOES AWAY WE HAVE TO BE CAREFUL ABOUT WHAT WE DO IT WILL EXAS ARE BAIT THE PROBLEM.

>> Renee: ANY OTHER COMMENT ON THAT?

>> IN RESPONSE IN DIRECT RESPONSE TO THE QUESTION, THESE NETWORKS AND ESTABLISHING NETWORKS AND REFERRAL NETWORKS WHICH IS WHY THE MAJOR HOSPITALS ARE GOING OUT AND BUYING RURAL HOSPITALS, THAT IS ALL PART OF BASICALLY THE REQUIREMENTS TO GET REIMBURSED IS THAT YOU HAVE TO HAVE REFERRAL NETWORKS.

SO IT'S NOT LIKE YOU HAVE A CHOICE.

THESE ARE CONSTRAINTS IN THE SYSTEM THAT ARE BEING PUT UPON US THAT WE HAVE TO FOLLOW.

SO IT'S NOT LIKE U.K. OR U OF L IS DOING GREAT AND THEY ARE SPENDING MONEY TO BUY RURAL HOSPITALS THAT IS NOT THE MOAT INDICATION HERE AT ALL.

>> BETH SMITH SAYS THIS... ANY MEANINGFUL OR SINCERE PLANS TO KEEP UP THE LOW DISAFFING AND SAFETY ISSUES IN LONG-TERM CARE IN KENTUCKY PATIENTS ARE AT SIGNIFICANT RISK AND NO ONE SEEMS TO CARE.

THAT IS A DIFFERENT -- A DIFFERENT BUNCH OF FRUIT THERE, ANYONE CARE TO CHIME IN TALKING ABOUT LONG-TERM CARE.

>> THAT IS A FAIR ASSESSMENT UNFORTUNATELY IT IS I'VE BEEN CONCERNED ABOUT THE LONG-TERM CARE INDUSTRY FOR SEVERAL YEARS AND WE'VE TALKED ABOUT HOSPITALS BUT NURSING HOME SITUATION IS PROBABLY MORE CRITICAL.

THEY HAVE NOT SEEN SUBSTANTIAL INCREASES IN YEARS WHICH IS UNFORTUNATE.

AND IT GOES BACK TO FUNDING AND THE TRAGIC SITUATION WE SPEND TWO TO THREE TIMES MORE ON HEALTHCARE BUT OUR OUTCOMES ARE TERRIBLE.

WE HAVE TO HAVE A PARADIGM SHIFT IN THIS COUNTRY.

AND TAKE BETTER ADVANTAGE OF THE DOLLARS THAT ARE OUT THERE.

I DON'T THINK WE NEED TO PUT MORE MONEY INTO HEALTHCARE WE NEED TO SPEND OUR MONEY MORE WISELY AND WE ARE NOT DOING THAT AND THERE'S TREMENDOUS OPPORTUNITIES I MENTIONED THE BUREAUCRACY OF IT.

IMMEDIATELY THERE COULD BE BILLION DOLLARS SAVINGS BUT WE NEED TO FOCUS ON IMPROVING THE HEALTH OF OUR POPULATION AND HAVE ACCOUNTABILITY.

WE HAVE BEEN UNDER MANAGED CARE FOR 10 YEARS NOW, AND THEY ARE GETTING A GOOD PIECE OF OUR MEDICAID BUDGET BUT THEY HAVE NOT IMPROVED OUR POPULATION AND IT STARTS AT THE LOCAL LEVEL AND WE HAVE NOT HAD THE STRUCTURE IN PLACE TO HAVE THAT MODEL AND WE SHOULD.

>> IT'S STRANGE FOR A PROVIDER TO SAY THEY AGREE THAT IT'S NOT NECESSARILY MORE MONEY IT'S REPURPOSING IT WITHIN THE SYSTEM.

AND OUR SYSTEM OF REIMBURSEMENT IS STRUCTURED ON PAYING NOT SO MUCH PAYING FOR PREVENTING OR STOPPING.

THERE'S A MOVEMENT NATIONALLY IN VALUE-BASED CARE AND PURCHASING YOU'VE PROBABLY HEARD OF THAT.

KENTUCKY'S BEEN SLOW IN ADOPTING IT.

WE'RE MOVING IN THAT DICK TRICK.

ABOUT -- DIRECTION.

HALF OF OUR PATIENTS THAT ARE SEEN ARE IN SOME TYPE OF VALUE BASED PROGRAM.

STILL LOW LEVEL AT THIS POINT IN TIME.

BUT I THINK YOU'LL START SEEING MORE AND MORE SHIFTS AS THAT HAPPENS THE CONTINUUM OF CARE WILL START EVOLVING AS WELL.

SO THAT IN PARTICULAR IF YOU LOOK AT MEDICARE POPULATION THEN THE AFTER CARE THAT IS GOING TO HELP PREVENT READMISSIONS INFECTIONS AND OTHER THINGS THAT CAUSE A LOSS OF VALUE, I HATE TO USE THAT TERM IN HEALTHCARE BUT IT'S THERE ALL THE TIME.

AND IT IS A MARKER OF QUALITY AND COST, BUT THE VALUE THAT'S DRIVEN BY A CONTINUUM OF CARE THAT IS MEETING THE NEEDS OF THE PERSON TO PREVENT HIGHER COSTS BAD CARE FROM HAPPENING AND BAD RESULTS AND HARM TO THE PATIENT, WILL BE REWARDED.

AND SOME STATES ARE FURTHER ALONG THAN WE ARE.

>> Renee: WHY IS KENTUCKY SLOW TO ADOPT THIS, MR. CHAIRMAN IS THIS AN IDEA YOU WOULD ENTERTAIN?

>> WE DON'T HAVE A STRONG PRIMARY CARE BASE IN KENTUCKY.

AND IT'S BEEN A SLAP A BAND-AID HERE AND THERE AND TO USE A ANALOGY.

UNLESS WE ADDRESS THE PRIMARY CARE SITUATION, WE'RE NOT GOING TO MAKE THAT KIND OF PROGRESS BECAUSE THAT'S THE FOUNDATION OF HEALTHCARE AND IT'S JUST NOT DEVELOPING.

50% OF OUR POPULATION IS RURAL KENTUCKY.

ONLY 17% PRIMARY CARE PHYSICIANS ARE IN RURAL KENTUCKY.

WE HAVE TO ADDRESS IT AND DO THAT IMMEDIATELY.

>> SENATOR BERG.

>> IT ALSO GOES BACK TO AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE.

IF YOU DON'T HAVE THE WHEREWITHAL, FIRST OF ALL, NOBODY'S GETTING REIMBURSED TO TRY TO MAKE PEOPLE NOT EVER GET SICK.

WHICH WOULD BE THE IDEAL.

YOUR MODEL WOULD BE BASED ON HOW MANY PATIENTS ARE HEALTHY AND DON'T NEED ACCESS TO HEALTHCARE.

THAT IS NOT HOW THE SYSTEM IS SETUP.

THE SYSTEM YOU GET REIMBURSED FOR ACUTE CARE.

YOU GET REIMBURSED FOR ACTUALLY HAVING SOMEBODY SICK IN FRONT OF YOU THAT YOU ARE DOING SOMETHING WITH.

AND THAT IS OPPOSITE OF WHAT ACTUALLY WE REALLY NEED.

SO I AM A HUGE PROPONENT OF THE PUBLIC HEALTH MODEL WHERE WE SPEND MORE MONEY AND MORE DOLLARS EDUCATING MORE PEOPLE.

AND TRY TO GET THE MESSAGE OUT JUST THINGS AS SIMPLE AS WEARING A SEATBELT SAVES LIVES.

NOT ONLY DOES IT SAVE LIVES IT SAVES MILLIONS OF DOLLARS IN HEALTHCARE COSTS.

THAT WE DON'T HAVE TO SPEND TAKING CARE OF YOU BECAUSE YOU DIDN'T GET HURT AS BADLY.

THOSE TYPE OF MESSAGES WHERE WE ACTUALLY PROMOTE HEALTH WE PROMOTE WELLNESS, WE SPEND OUR MONEY MAKING PEOPLE BETTER TO BEGIN WITH SO THAT WE DON'T HAVE TO SPEND SO MUCH MONEY.

SOMETHING LIKE 90% OF HEALTHCARE DOLLARS ARE SPENT IN THE LAST YEAR OF LIFE?

IT'S JUST AN OVERWHELMING FIGURE.

WE JUST NEED TO REIMAGINE WHAT HEALTHCARE DELIVERY CAN ACTUALLY LOOK LIKE.

>> TO THAT POINT, YOU KNOW, STEVE AND Dr. BERG, I MEAN, THE FEDERAL GOVERNMENT GIVES LIP SERVICE TO THE FACT THAT THEY ARE TRYING TO HAVE ALIGNMENT THEY ARE TRYING TO PROMOTE COLLABORATIONS, TRYING TO HAVE THE YOU KNOW, ACCOUNTABLE CARE ORGANIZATIONS THAT WE HAVE VALUE BASED REIMBURSEMENT AND THIS IS HOW WE'RE GOING TO WORK TOGETHER.

BE IT A HOME FOR A MEDICAL HOME FOR SOMEONE AND WE'RE GOING TO WORK TOGETHER TO MAKE THIS HAPPEN.

YET ON THE OTHER HAND, THIS ADMINISTRATION THE BIDEN ADMINISTRATION HAS TAKEN A STRANGE POSITION TOWARD CONSOLIDATIONS, PARTNERSHIPS AND COLLABORATIONS AND REALLY SAYING BY EXECUTIVE ORDER THAT THE PRESIDENT INTERRED AN EXECUTIVE ORDER SAYING TO THE FEDERAL TRADE COMMISSION THAT THEY WANT THEM TO CRACKDOWN ON THESE KINDS OF COLLABORATIONS THE CONSOLIDATIONS SO IT JUST IS SO CONFUSING BECAUSE I THINK FOR THE RURAL PROVIDERS IT'S GOING TO BE HELPFUL TO HAVE THOSE KINDS OF COLLABORATIONS AND PARTNERSHIPS.

LIKE FOR SPECIALISTS, IF YOU ARE LUCKY ENOUGH TO HAVE A PRIMARY CARE DOCTOR YOU MAY OR MAY NOT BE ABLE TO HAVE A SPECIALIST YOU NEED TO HAVE THE STRONG COLLABORATIONS WITH A LARGER SYSTEM WHERE YOU CAN BRING THE SPECIALISTS TO BEAR OR SPECIAL EQUIPMENT THAT ARE TOO EXPENSIVE TO BE ABLE TO BE PROLIFERATED THROUGHOUT THE STATE OR WHATEVER.

I REALLY THINK WE NEED TO BE VERY CAREFUL ABOUT THIS THREAT FROM THE FTC THEY ARE GOING TO BE CRACKING DOWN ON THESE COLLABORATIONS, BECAUSE ESSENTIALLY ON THE ONE HAND THE FEDERAL GOVERNMENT IS SAYING WE WANT YOU TO COLLABORATE AND PARTNER AND WORK TOGETHER TO HELP IMPROVE THE HEALTH OF EACH INDIVIDUAL AND ON THE OTHER HAND, EVERYBODY GETS NERVOUS.

SO I THINK I DO THINK THAT IT'S VERY IMPORTANT FOR OUR THE HEALTH OF OUR RURAL HOSPITALS AND FOR PHYSICIANS THAT THEY HAVE THOSE KINDS OF STRONG PARTNERSHIPS THAT ARE BACK TO A LARGER SYSTEM THAT CAN HELP SUPPORT THEM AND BRING NEEDED HEALTHCARE TO THE RURAL KENTUCKIANS.

>> WHILE THE FEDERAL GOVERNMENT IS DOING THAT THEY ARE MISSING THE MOST OBVIOUS THINGS LET'S TALK ABOUT THE EMERGENCY CARE IN RURAL COMMUNITIES.

MY SMALL HOSPITAL AGAIN 26,000 POPULATION, WE HAD CLOSE TO 24,000 ER VISITS A YEAR.

REALLY?

67% OF THOSE WERE PRIMARY CARE VISITS.

WHY ARE THEY KEMPING TO THE ER?

BECAUSE WE DON'T HAVE THE PRIMARY CARE PHYSICIANS TO TAKE CARE OF THE VOLUME.

BUT BECAUSE THE FEDERAL GOVERNMENT AND THE LACK OF REFORM ANYONE WHO PRESENTS TO ER REGARDLESS OF WHAT THE COMPLAINT IS THAT IS AN EMERGENCY SITUATION THEY ARE GOING TO BE TREATED LIKE AN EMERGENCY PATIENT WHEN THEY ARE PROBABLY NOT.

THEY WILL GET A COMPLETE WORK UP WHICH THEY WILL NOT NEED AND IT IS A WASTE OF RESOURCES AND HOW ARE WE GOING TO PAY FOR THIS?

IT'S THERE ALREADY WITHIN THE SYSTEM IF WE SPEND THE DOLLARS THE RIGHT WAY WHICH WE JUST DON'T DO.

>> I THINK THAT THESE ARE ALL RELEVANT ISSUES.

BUT I WANT TO MAKE SURE THAT WE ARE THINKING ABOUT HOW PATIENTS NAVIGATE THE SYSTEM.

IT'S SO COMPLICATED.

IT IS SO FRAGMENTED.

AND TO EXPECT A PATIENT TO KNOW WHERE TO GET CARE, WHEN TO GET CARE, WHETHER THAT CARE IS GOING TO BE COVERED OR IF THEY ARE GOING TO GET A SURPRISE OUT-OF-NETWORK BILL, OR JUST BE BALANCE BILLED FOR ONE THING OR ANOTHER AT A RATE THAT YOU WOULD NOT HAVE IMAGINED FOR WHAT SEEMED TO BE A SIMPLE PROCEDURE OR ISSUE, IT'S JUST A REALLY HARD SYSTEM FOR CONSUMERS FOR KENTUCKIANS TO BE ABLE TO NAVIGATE AND TO FEEL CONFIDENT THAT THEY ARE GOING TO GET THE CARE THEY NEED AND NOT BE A RISK OF BANKRUPTCY OR HAVE BAD DEBT HANGING OVER THEIR HEADS FOR YEARS.

AND SO I THINK THAT ONE THING THAT IS POSITIVE AND I LIKE TO MAKE SURE WE'RE ALSO UPLIFTING THE GOOD THINGS WE'RE DOING HERE IN KENTUCKY THERE WAS A BILL PASSED LAST YEAR BY REPRESENTATIVE KIM MOSHER AND IT WAS TO HAVE COMMUNITY HEALTH WORKERS BILL MEDICAID SO THEY ARE NOW MEDICAID REIMBURSABLE.

AND IT IS A FANTASTIC OPPORTUNITY FOR US TO HAVE INDIVIDUALS WHO ARE REALLY YOUR NEIGHBORS PEOPLE THAT YOU KNOW AND TRUST IN YOUR COMMUNITY WHO YOU CAN NOW GO TO TO HELP YOU NAVIGATE THE HEALTH SYSTEM TO DO THE CARE COORDINATION THAT MIGHT BE LACKING IN DIFFERENT SYSTEMS BECAUSE THERE IS SO MUCH FRAGMENTATION AND TO DO A LOT OF HEALTH EDUCATION AND PROMOTION AND FOCUS ON PREVENTION.

AND I THINK THAT IF WE CAN GROW THIS NETWORK OF COMMUNITY HEALTH WORKERS ESPECIALLY IN RURAL AREAS WE'RE GOING TO BE ABLE TO CUT DOWN ON A LOT OF THAT UNNECESSARY COST BUT WE'RE JUST GOING TO BE DELIVERING HEALTHCARE IN A WAY THAT.

>> Renee: HOW DO PATIENTS KNOW ABOUT COMMUNITY HEALTH WORKERS?

>> WE DON'T HAVE A LOT RIGHT NOW.

ALTOGETHER IN KENTUCKY, WE HAVE HUNDREDS, WE HAVE ABOUT 200 WHO ARE CERTIFIED RIGHT NOW AND THE CERTIFIED COMMUNITY HEALTH WORKERS HAVE GONE THROUGH ADDITIONAL TRAINING AND THEY ARE THE ONES THAT ARE ABLE TO BILL MEDICAID WORKING WITH A PROVIDER A MEDICAID BILLABLE PROVIDER.

WE NEED TO GROW THIS NETWORK.

WE HAVE CERTAIN POCKETS AROUND THE STATE EASTERN KENTUCKY MORE THAN OTHER AREAS.

BUT THIS IS A GREAT OPPORTUNITY FOR US.

>> Renee: Dr. HOUGHLAND?

>> PRIMARILY FIND OUT ABOUT IT THROUGH WORD OF MOUTH AND IT DRIVES A LOT OF DECISION MAKING IN HEALTHCARE TODAY DESPITE ALL THE INFORMATION WE HAVE AND THAT IS SCARY.

THEIR INSURER AND PROVIDER.

BACK A LITTLE BIT TO THE WORKFORCE IF I COULD.

I'M SORRY JUMPING AROUND A LITTLE BIT.

WE'VE TALKED A LOT ABOUT THE ISSUE THAT WE DON'T HAVE ENOUGH CLINICIANS IN PRIMARY CARE EIGHT YEARS AGO THERE WAS AN EFFORT TO INCREASE THE NUMBER OF GRADUATES FROM SCHOOLS.

AND WE WERE SUCCESSFUL IN DOING THAT.

BUT THERE WASN'T A COMMON INCREASE IN THE RESIDENCY TRAINING POSITIONS IN PRIMARY CARE.

THERE WAS A LITTLE SHIFT BUT NOT AS MUCH.

SO THERE IS A PROBLEM THAT WE DON'T HAVE ENOUGH PEOPLE COMING OUT OF MEDICAL SCHOOL OR NURSING SCHOOL WITH ADVANCED DEGREES TO BE TRAINED IN PRIMARY CARE.

SO IT DIDN'T REALLY HELP THAT MUCH.

AND THEN WHENEVER THE REIMBURSEMENT THE SALARY STRUCTURE IS WHAT IT IS IT DOESN'T INCENTIVIZE PEOPLE TO SEEK PRIMARY CARE AS A CAREER.

SO THERE'S OPPORTUNITIES THERE.

THERE'S EFFORTS SUCCESSFULLY IN GETTING SOME PRIMARY CARE TRAINING PROGRAMS IN RURAL COMMUNITIES WHICH IS A REAL POTENTIAL OPPORTUNITY TO KEEP PEOPLE IN THEIR COMMUNITIES WHERE THEY GREW UP.

THEY TRAIN.

AND THEN THEY GO TO WORK.

IF WE CAN GET UPSTREAM AND IDENTIFY PEOPLE IN HIGH SCHOOL BEFORE THEY GO TO COLLEGE, AND THEN BEFORE THEY GO TO MEDICAL SCHOOL OR NURSING SCHOOL TO KEEP THEM TO RETAIN THEM MORE THAT IS A GOOD OPPORTUNITY.

WE'RE WORKING ON THAT AS A STATE.

OTHERS ARE DOING IT AS WELL.

IT IS A MODEL WE CAN LOOK AT AND GROW MORE.

AND I THINK THAT IS REALLY INTERESTING AND EXCITING FOR US.

>> I THINK U OF L -- >> WE ARE KNOW WE HAVE URBAN DESERTS AS WELL AND IT GOES BACK TO THE POOR REIMBURSEMENT FROM MEDICARE AND MEDICAID.

I PASSED A BILL, IT WAS SENATE RESOLUTION 54 WHICH ASKS THE MEDICATE DEPARTMENT TO BUILD A PAYMENT METHODOLOGY IN THE COMMUNITIES THAT ARE MOST DEPRIVED SHOULD GET HIGHER REIMBURSEMENT AND MORE RESOURCES TO TURN THAT I'M HOPING THAT WILL ADDRESS THAT PROBLEM AND WHY WOULDN'T WE DO THAT IF WE INVEST IN THOSE COMMUNITIES IT WILL IMPROVE THE QUALITY OF LIFE FOR THOSE PEOPLE.

IT WILL IMPROVE HEALTHCARE OUTCOMES AND SAVE THE SYSTEM MONEY WHICH HELPS IT FOR EVERYONE ELSE.

>> IF YOU COUPLE THAT WITH WHAT YOU U OF L AND U.K. ARE DOING THEY'VE HAD SOME SUCCESS IN WHENEVER THEY HAVE THEIR EDUCATION PROGRAM THEY ARE EDUCATING THEM IN THE AREA THAT THEY WANT TO PRACTICE IN IN KENTUCKY.

THEY'VE NEVER REALLY BEEN DISPLACED.

THEY STAY RIGHT THERE THEY WANT TO BE PART OF THAT COMMUNITY SO THEY ARE HAVING A LOT OF SUCCESS IN TRYING TO KEEP THOSE INDIVIDUALS IN THEIR COMMUNITIES.

AND PARTICULARLY IF YOU CAN ADDRESS -- >> AND I THINK AS WE'VE TALKED ABOUT A LOT OF ISSUES WITHIN HEALTHCARE BUT AS EMILY SAID IF YOU GO BACK TO THE PATIENT AND WHAT IS THE PATIENT LOOKING AT AND WHAT IS THE PATIENT AS THEY LISTEN TO US TALK HERE TONIGHT, WHAT DO THEY SAY ABOUT OK WHAT IS GOING TO HELP ME.

LET ME THROW OUT TWO THINGS.

I THINK THAT CAN FIT INTO THE SYSTEM THAT WE HAVE NOW THAT I THINK WOULD MAKE A BIG DIFFERENCE.

WE ASKED OUR MEMBERS THE PHYSICIANS THE FRONTLINE WORKERS WHAT IS THE NUMBER ONE ISSUE?

AND THEY TOLD US THE NUMBER ONE ISSUE IS PRIOR AUTHORIZATION AND ADMINISTRATIVE HASSLES.

WE ALL TALKED ABOUT IT OUT IN THE HALLWAY BEFORE WE GOT STARTED IN HERE.

AND HOW THE INSURANCE COMPANIES ARE CREATING THESE BARRIERS FOR PATIENTS.

AND THESE ARE REAL BARRIERS AND OUR MEMBERS GO THROUGH THE BARRIERS EVERYDAY AND TRY TO NAVIGATE THE BARRIERS FOR THE PATIENT.

BUT WHEN WE TALK ABOUT COST, AND THE COST OF CARE, NO ONE TALKS ABOUT THE PATIENT COST.

IF THE PATIENT HAS TO PAY SOMETHING OUT OF POCKET BECAUSE IT'S BEEN DENIED THAT DOESN'T GO INTO THE CALCULATIONS THAT WE HAVE FOR THE COST OF CARE BUT THAT IS HAPPENING EVERY SINGLE DAY.

AND IT IS REALLY FRUSTRATING I KNOW FOR MY MEMBERS BUT ESPECIALLY FRUSTRATING FOR THE PATIENTS WHO HAVE TO GO THROUGH IT.

AND I THINK THAT THERE ARE MODELS OUT THERE THAT WE CAN REFORM THAT SYSTEM HERE IN THIS STATE JUST LIKE THEY'VE DONE IN OTHER STATES AND REFORM AT LEAST THE PRIOR AUTHORIZATION SYSTEM TO DO THAT.

THE OTHER THING THAT I THINK WOULD BE HELPFUL AND THERE WAS A NATIONAL ARTICLE ABOUT IT THIS MORNING, IS AROUND WHAT IS CALLED PHARMACY BENEFIT MANAGERS OR PBM'S.

HEALTH PLANS WORK WITH THESE PBM'S TO THEY SAY MANAGE THE COST OF DRUGS.

BUT AS THIS ONE ARTICLE TALKED ABOUT, SOME OF THE PBM'S ARE OWNED BY THE HEALTH INSURANCE COMPANIES WHO ALSO OWN THE PHARMACIES.

AND THEN YOU SEE THE PRICES SKYROCKET ON THESE PARTICULAR DRUGS.

AND I THINK IT WOULD BE NICE TO REIN THAT IN.

BECAUSE I THINK AS CONSUMERS WE PAY A LOT OF MONEY OUT OF POCKET FOR THESE DRUGS AND IT WOULD BE NICE TO NOT HAVE TO GO THROUGH THAT AND KNOW THAT THE INSURANCE COMPANY ONE WAY OR ANOTHER IS MAKING A LOT OF MONEY BUT I'M HAVING 0 PAY MORE OUT OF POCKET.

>> WE'VE TALKED A LOT ABOUT COSTS.

REALLY WE'RE TALKING ABOUT IS CHARGES.

WE'RE NOT LOOKING AT THE ACTUAL COSTS IN MOST SETTINGS.

SOME WE HAVE A GOOD IDEA THE NOT-FOR-PROFIT HOSPITALS WE HAVE A GOOD IDEA WHAT THE COSTS ARE BECAUSE WE CAN LOOK AT THE 990s.

OTHERS NOT SO MUCH.

BUT TO THINK IT'S IMPORTANT TO LEVEL THAT WE TALK A LOT ABOUT CHARGES NOT THE ACTUAL COST OF DEVELOPING AND RENDERING THE SERVICE.

>> Renee: WE'VE GOT A LOT OF GOOD QUESTIONS AND WE PROBABLY WON'T GET TO THEM BECAUSE WE HAVE TWO MINUTES LEFT.

BUT THIS IS ONE PERHAPS AND I SHOULDN'T THROW IT OUT IT IS A GOOD QUESTION SINCE LAWS WERE ALLOWED TO ALLOW MEDICATIONS TO BE ADVERTISED, BIG PHARMA AND FOR-PROFIT MEDICINE HAS ADOPTED PATIENT CARE CAN WE ENVISION A TIME WITH FEE FOR SERVICE?

>> WOULDN'T THAT BE WONDERFUL.

>> .

>> Renee: THAT'S THE RESPONSE YOU GET.

YES.

A COLLECTIVE SIGH THERE.

ANY FURTHER RESPONSE?

>> IT DEPENDS ON WHAT YOUR DEFINITION OF FEE OR SERVICE TECHNICALLY THE SYSTEM WE HAVE IS FEE FOR SERVICE.

THERE IS AN INTERMEDIARY IS THAT IS RESPONSIBLE FOR PAYING THE CLAIMS LARGELY BORN BY ALL OF US.

AND OUR EMPLOYERS THROUGH SOME FORM OR FASHION OR THROUGH AS PART OF OUR TAX PAYMENTS.

BUT TECHNICALLY MOST OF US ARE PARTICIPATING IN A FEE FOR SERVICE MODEL TODAY.

OUTSOURCED PAYER MODEL.

>> CONFUSION WHAT THAT REALLY MEANS AND IT'S.

>> AGAIN, I THINK THE COST IF THEY ARE TALKING ABOUT THE COST OF DRUGS THE WAY THE DRUG COMPANIES ADVERTISE WHAT THEIR DRUGS CAN DO, THAT'S FINE.

I DON'T KNOW THAT THAT'S CREATED THE BOTTLENECK WHAT'S CREATED THE BOTTLENECK IS THE DRUGS ARE SO EXPENSIVE FOR REASONS THEY DON'T NEED TO BE IN MANY CASES AND I THINK THERE ARE WAYS TO REIN IN THOSE COSTS WHETHER THEY ARE ADVERTISED OR NOT.

>> AND THAT IS WHY THE 340B PRICING PROGRAM IS SO IMPORTANT FOR PATIENTS AS WELL BECAUSE IT WILL TAKE CARE OF A LOT OF THOSE EXPENSIVE DRUGS THAT COST OF THAT.

AT A COUNTED RATE OR NO CHARGE IF THAT IS REMOVED BY THE FEDERAL GOVERNMENT THAT COULD JUST MAKE THIS PROBLEM WORSE.

>> Renee: WE'LL HAVE TO LEAVE IT THERE.

WE SHOULD DO AN OVERTIME SOMETIME BECAUSE WE'VE GOTTEN GOOD QUESTIONS.

WE THANK YOU VIEWERS AT HOME 4 YOUR GREAT QUESTIONS TONIGHT.

JOIN US NEXT MONDAY AT 8 EASTERN, 7 CENTRAL FOR "KENTUCKY TONIGHT" AGAIN WE WILL HAVE A TOPIC THAT YOU WILL BE INTERESTED IN AND JOIN US EACH WEEKNIGHT AT 6:30 EASTERN FOR KENTUCKY EDITION WHERE WE INFORM, CONNECT AND INSPIRE AND BILL BRYANT WILL BE HERE FRIDAY WITH THE JOURNALISTS TO TALK ABOUT THE WEEK'S NEWS.

THANK YOU FOR JOINING US.

I'M RENEE SHAW AND I WILL SEE YOU TOMORROW NIGHT.