Highlight on Kentucky: Provider Shortage Spawns Creative Practices in the Bluegrass State

As the nation faces what has been characterized as a primary care shortage, due at least in part to the implementation of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) and the resulting increase of newly insured individuals, some states have acted to offset the provider shortfall. Kentucky, a state which has been reported as lagging behind the primary care physician-to-citizen ratio, is among those states taking at least a creative approach to the looming shortage. While at least one of these practices, which involved stepping up the responsibilities and authority of nurse practitioners, has been widely reported as following the trend of many other states that are working to quell the primary care shortage, another path has been drawn to target other types of underserved patients.

Physician Shortage Nationwide

According to data reported by the Association for American Medical Colleges (AAMC) and the Health Resources and Service Administration (HRSA), the nation overall and especially certain rural areas are beginning to face a severe shortage of health care providers. In sum, the HRSA report highlights the following: (1) almost 20 percent of Americans live in areas that have an insufficient number of primary care physicians and (2) 16 percent of Americans live in areas with insufficient numbers of dentists. Perhaps what is most shocking is the final result that was highlighted in that study that indicated 30 percent of Americans reside in areas where there is a shortage of mental health providers. The AAMC predicts that by 2020 there will shortage of 45,000 primary care physicians and an equal number of needed but non-existent specialists.

Kentucky Shortage

While some reports indicate that these predictions were incorrect or have at least failed to come to fruition as of yet, local sources in Kentucky outlined its provider shortage in no uncertain terms. In particular, this report included data offered by the Kentucky Rural Medical Educators Conference, which asserted that “Kentucky had a 1,287:1 primary care physician-to-citizen ratio, 557 short of the national average.” Additionally, the HRSA data lists Kentucky as among the states with the lowest per capita number of psychologists and mental health counselors.

Targeting Mental Health

While Kentucky has recently passed a law empowering nurse practitioners to prescribe medication, presumably to fill the shortage of primary care providers, it also has adopted a measure to target the shortage of mental health providers. Specifically, through the passage of a new law, Kentucky recently became the sixth state to allow pastoral counselors to become licensed as mental health counselors. According to a local source, the state joined Arkansas, Maine, New Hampshire, North Carolina, and Tennessee to provide this licensing option for pastoral counselors. It appears in doing so, the state officials hoped that this option would encourage increased numbers of pastoral counselors to become mental health counselors and fill the void of mental health care professionals in the state.

As it has been noted in nationwide data, the demand for mental health care professionals, like primary care providers, is expected to grow as more individuals take advantage of coverage options under the ACA. In terms of mental health, the combination of the ACA mental health benefits and the Mental Health Parity and Addiction Equity Act is also projected to increase numbers of potential new patients in this field, creating more demand for providers. Critics of the law have asserted the importance of maintaining differentiation between mental health providers and pastoral counselors, who may be swayed by spiritual factors and are generally thought to be not in the same category as non-pastoral counselors, as reasons for blocking its passage previously. Yet the report also noted that pastoral counselors often serve clients outside of churches and treat patients of different faiths and denominations. Additionally, the training requirements for pastoral counselors are often more stringent than those requirements for certain types of mental health counselors.

Jim Beall: California’s Mental Health Parity Violation ‘Terminator’

Insurers must obey the California mental health parity laws or pay a hefty sum, according to the recently passed California Senate bill (SB) 1046. Senator Jim Beall (D) introduced the consumer-minded bill to address insurance companies’ violations of the parity laws and to give penalty authority to California’s Department of Insurance (DOI), the state’s regulator of self-employer and individual insurance plans, as the Department of Managed Health Care (DMHC), the state’s health plan regulator in February 2014.

A chair of the Senate Mental Health Caucus, Beall said the bill “puts health insurers on the alert that they must live up to the law or face fines’’ of up to $2,500 per day. The existing California law allows the DMHC to levy per-day penalties for on-going mental health parity violations. However, California’s codes do not give the DOI the same authority, and some private insurers are taking advantage. The new law will allow the DOI to impose the fines and close loopholes for insurance companies seeking to escape the parity laws. The DOI handles approximately 10 percent of health care consumers.

Mental health parity also was addressed in the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), which requires that inpatient, outpatient, and emergency mental health services be available to underserved populations. A Final rule (78 FR 12834) issued by HHS in February 2013, implemented the ACA to require Exchanges and insurance issuers to cover mental health and substance use disorder services as one of the 10 essential health benefits (EHB) categories for the individual and small group markets. Section 1302 of the ACA implemented an EHB package that includes coverage requirements, cost-sharing limits, and actuarial value requirements for health plans. This paved the way to 2014 parity requirements, under which all health plans, including those sold through Exchanges or Marketplaces, must offer coverage of mental health services comparable to coverage of medical and surgical benefits. The ACA requirements comply with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), which previously established parity requirements, but did not apply them to health plans without coverage for mental health care or to companies with less than 50 employees.

Other states, such as Washington, have been experiencing similar insurance parity violations, in which blanket exclusions on medically necessary mental-health care services are imposed and left out of policy text.

Beall strives to terminate the loopholes insurers have found and improve access to mental health care. According to Beall, there are approximately 2 million insured Californians who could not get needed mental health services. Beall has championed several health insurance efforts including his creation of the Children’s Health Initiative to provide every child in Santa Clara County with health insurance and his legislation to help foster care children, low-income families, and people with disabilities.

SB 1046 was passed by the state assembly on August 4, 2014, and is awaiting Governor Jerry Brown’s approval.

Highlight on Maine: Maine Tightens TANF Benefits with Drug Test Enforcement

By Lisa A. Weder

In a push to make Maine’s residents more self-sufficient, Governor Paul R. LePage (R-Me.) says it’s time to enforce a drug testing law on convicted drug felons who receive or apply for welfare benefits. On Wednesday, August 6, 2014, the former businessman turned governor announced that the Maine Department of Health and Human Services (Maine HHS) will carry out its plans to drug test those felons who receive Temporary Assistance for Needy Families (TANF) benefits.

TANF benefits are funded under Part A of Title IV of the Social Security Act (SSA), as amended by sec. 5507 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), which awards states grant funding to provide health services and education and job training to low-income individuals. TANF benefits are designed to:

  • Assist needy families in ways that children can be cared for in their own homes;
  • Promote job preparation, work, and marriage to foster independence in needy parents;
  • Prevent and reduce out-of-wedlock pregnancies; and
  • Encourage the formation and maintenance of two-parent families.

Welfare reform was a large part of Maine’s 2012-2013 budget, which implemented a new five-year limit on welfare benefits. The governor’s reasoning for instituting the drug-testing policy revolves around spending tax dollars wisely. “Maine people expect their tax dollars to be spent supporting our most vulnerable citizens—children, the elderly and the disabled,” said LePage. “We must ensure that our tax dollars do not enable the continuation of a drug addiction.” The thought is that someone using drugs will misspend TANF assistance funding and put their family’s needs on the back burner. The governor asserts that being drug-free enables welfare beneficiaries to move away from poverty and toward financial independence.

Maine HHS has implemented its drug-testing procedures and program with best practices, privacy, fairness, and accountability in mind, according to Maine HHS Commissioner, Mary Mayhew. When a person applies for TANF benefits, the individual must indicate whether he or she has a prior drug-related felony conviction. If that is the case, the state will schedule a drug test and notify the person 24 hours prior to the actual test. A person testing positive the first time can take the test one more time. According to Maine’s state website, a first offense results in the termination of adult benefits, and a second offense may result in the family’s loss of benefits. The tests are funded by the state.

To avoid termination of welfare benefits, an afflicted individual may enroll in an HHS-approved substance abuse program. Persons failing to disclose that they are convicted drug felons violate the program rules and face immediate termination of TANF benefits.

Maine’s new rule was originally introduced in 2011, but becomes effective October 1, 2014. Some question why the governor is enforcing the policy now in light of the fact that Maine is ranked 47th in terms of job creation. Portland, Maine’s local news channel, WCSH6, interviewed Democratic political analyst Ethan Strimling who said that “ … in terms of getting people off welfare, it’s not going to do us much good.” The policy will be published in August 2014 and will be subject to a public hearing and final approval by the Attorney General’s office.

The question yet to be answered is whether Maine’s drug testing policy will help or hinder families receiving TANF benefits.

AHA Looks Through Congress Towards CMS, Urges Transparency

The American Hospital Association (AHA) wrote a letter encouraging members of the Senate to increase access to health care data while maintaining patient privacy and the security of patient information. The letter seeks to uncover the currently unavailable wealth of CMS data, which AHA says can be used to improve upon the quality and value of health care. Through measures that are targeted at CMS, AHA believes data sets can be made into accessible, practical, and efficient tools for research and progress.


The letter focuses on Medicare claims data that CMS, at present, makes only partially available. AHA recommends that CMS be required to make data from across the continuum of care accessible, so that opportunities for improvement in the quality of care can be identified for the whole continuum of care. To effectuate that goal, AHA says that the Part B Carrier and the Part B Durable Medical Equipment limited data set (LDS), the standard analytic files (SAF), and the Part D prescription drug data should be made accessible to interested parties and researchers. Part of the AHA recommendation is to have CMS streamline current practices. For example, AHA suggests that the access to research identifiable files (RIFs) be simplified from the current system, which requires a review board approval for each project, to a system where researchers are granted a “one-time clearance” from the review board for a specified period of time.


The AHA also expresses in the letter its support for initiatives to improve price and quality transparency among providers. For example, the letter indicates AHA’s support for the Health Care Price Transparency Promotion Act (H.R. 1326), which would impose a requirement on states to have or establish laws requiring hospitals to disclose price data for certain services.As part of its involvement in a Healthcare Financial Management Association (HFMA) report, which the AHA attached to its letter, the AHA identified that health plans are best situated to pass along pricing data to insured patients. In keeping with that understanding, the letter recommends to congress that health plans should be the primary source of pricing information for insured patients. AHA also recommends that CMS publish additional quality data while maintaining awareness about the comparative usefulness and relevance of the data it provides.


In a separate section, the AHA sets out several cautionary statements regarding the need for prudence as data access grows. The letter emphasizes that “caution must be exercised to ensure privacy and security is maintained.” The AHA letter includes a reminder to congress that de-identified data can be reconnected to individuals with relative ease. In light of the ease of extrapolating protected information from health care data, the letter urges congress to exercise a heightened level of caution when considering making information available to entities that are not considered covered entities under the Health Insurance Portability and Accountability Act (HIPAA) (P.L. 104-191).