Behavioral Health

CMS Approves Work Requirement/Community Engagement & Prior Quarter Coverage Elimination Waivers; Denies 5-Year Eligibility Limit

Last week the Centers for Medicare and Medicaid Services (CMS) approved Arizona’s request to include work requirements and/or community engagement and reporting requirements as a condition of Medicaid enrollment beginning on January 1, 2020.  CMS also approved the request to eliminate prior quarter coverage eligibility effective April 1, 2019.  An accompanying directed waiver request to limit lifetime Medicaid eligibility to 5 years for “able-bodied adults” was denied by CMS. 

CMS’ Letter to Director Snyder is 18 pages long and contains conditions and details- so refer to that letter for the nuts and bolts of what they said.

The work requirement/community engagement Waiver request was filed many months ago and is mandated by Senate Bill 1092 (from 2015) which requires AHCCCS to ask CMS’ permission to implement new eligibility requirements for “able-bodied adults”. 

The program will require some “able-bodied” members between the ages of 19 to 49 years-old to participate in community engagement activities for at least 80 hours per month and report their activities monthly.  Activities can include employment, including self-employment; less than full-time education; job or life skills training; job search activities; and community service.

A member who fails to comply in any given month will be suspended from AHCCCS coverage for 2-months but automatically reinstated after that. Members won't be terminated for failing to comply.

The people exempted from the requirements include:

  • Pregnant women up to the 60th day post-pregnancy

  • Former Arizona foster youth up to age 26

  • Members of federally recognized tribes

  • Designated caretakers of a child under age 18

  • Caregivers who are responsible for the care of an individual with a disability

  • Members determined to have a serious mental illness (SMI)

  • Members who are “medically frail”

  • Members who have an acute medical condition

  • Members who are in active treatment for a substance use disorder

  • Members with a disability recognized under federal law and individuals receiving long term disability benefits

  • Full-time high school, college, or trade school students

  • Survivors of domestic violence

  • People who are homeless

  • People who receive assistance through SNAP, Cash Assistance or Unemployment Insurance or who participate in another AHCCCS-approved work program

Many things need to happen before the January 1, 2020 start date.  We’re hopeful that a robust evaluation component will be included in the program so that adjustments can be made to the policy over time and so that other states can learn from the Arizona experiment.

2018 Child Fatality Review Report Published

The death of any child is a tragedy – for the family and for the community. Everybody wants to prevent childhood deaths. But making policy interventions to prevent childhood deaths requires information in order to develop effective policy interventions.  That’s where the Arizona Child Fatality Review State Team comes in.

More than 25 years ago the state legislature passed a law establishing the Arizona Child Fatality Review Program (A.R.S. § 36-342, 36-3501-4).  It’s a great example of establishing public policy designed to build data and evidence so policy makers can use evidence to build future interventions.

The State Team includes representatives from the Academy of Pediatrics and from the ADES Divisions of Developmental Disabilities and Children and Family Services, as well as from law enforcement and the ADHS. The team’s role is to review all childhood deaths in AZ and produce an annual report to the Governor and legislature with a summary of findings and recommendations based on promising and proven strategies regarding the prevention of child deaths.

In past years this focus has raised the awareness about child drowning and the importance of putting babies to sleep on their backs or making sure all children are always secured in car seats. Other recommendations included taking action to reduce the number of uninsured, decrease medical complications of pregnancy and increase safe sleep practices.

The 2018 Child Fatality Review Report was published last week- and as usual it provides a host of data and recommendations that are directly tied to evidence. Here are some examples from this year’s report.

Child suicides increased an astonishing 32% and accounted for 6% percent of all child deaths. A history of family discord was the most commonly identified preventable factor in suicides followed closely by a history of recent break-up, drug/alcohol use and an argument with a parent. 

Firearm deaths increased 19% from the previous report.  Suicides and homicides accounted for 88% of firearm-related deaths in 2017. Fifty-one percent of firearm related deaths were a result of suicide (n=22) and 37% of firearm related deaths were homicides (n=16).

Injury deaths increased 4% from the previous reporting period and comprised 23% of all child deaths. The leading cause was car crashes and 31% of the injury deaths were among kids less than 1 year old… and important piece of data considering Arizona has yet to adopt a law requiring kids under 2 years old to be in a rear facing car seat.

The number of unsafe sleep deaths increased 5% from the previous year.  60% were bed sharing with adults and/or other children. Child fatalities due to maltreatment decreased 4% and accounted for 10% of all child deaths in Arizona.   Substance use was a factor in 65% of maltreatment deaths.

Drowning deaths increased 30% over the period and accounted for 4% of all child deaths. 63% occurred in a pool or hot tub. Lack of supervision was a factor in 69% of drowning deaths.

Substance use was a factor in 17% of all child fatalities (n=136).  The majority of substance use related deaths involved the child or the child’s parent as the main user contributing to the death of the child. In 49% of substance use related deaths, the parent was misusing or abusing alcohol or drugs.

The full report covers each of these areas including some recommendations for policy and program interventions in each area.  Sometimes the recommendations are more related to increasing awareness but many are more policy based.

Lots of work went into this report- so if you're somebody in a position to influence either lawmakers or agency officials to implement preventative policies in these areas- please get familiar with this   important research product - it will really help inform your advocacy efforts.

State Action to Stem Rising Prescription Drug Costs

By Association for State and Territorial Health Officials Staff

The high cost of prescription drugs is a persistent problem in the United States, with about 10 percent of overall health spending attributed to prescription drugs. In recent years, there has been increased interest among states to address the rising cost of prescription drugs. Just this year, 24 states passed 37 bills to stem rising drug costs. In total, state legislatures have introduced 160 bills targeting prescription drug costs in 2018.

States have pursued a wide range of strategies to tackle the high cost of prescription drugs, including policies that address drug price transparency, rate setting requirements to prevent price gouging, drug importation programs, generic drugs companies, and pharmacy benefit manager transparency.

 

Drug Price Transparency

Controlling healthcare costs is one of the three elements of the Triple Aim, along with improving population health and patient care experience. As a first step toward controlling costs, states are seeking more price transparency requirements from drug manufacturers. In 2018, six states passed legislation addressing drug price transparency. Many of these laws adopt more stringent transparency policies requiring drug manufacturers to justify price increases over certain thresholds. For example, Connecticut requires drug manufacturers to justify price increases for specific drugs if the price increases by 20 percent or more in a year or 50 percent over three years.

 

Price-Gouging and Rate Setting Requirements

Anti-price gouging and rate setting requirements use information collected from transparency laws to allow states to impose penalties for excessive drug price increases. Currently, Maryland is the only state with an anti-price gouging law. The policy allows the state Medicaid agency to notify the state’s office of the attorney general when an essential off-patent brand name drug or generic medication has an excessive price increase.

Maryland’s attorney general can then request justification from manufacturers for the price increase. If the rationale of the price increase is deemed unjustified by “the cost of producing the drug, or the cost of appropriate expansion of access to the drug to promote public health,” the state can impose civil penalties or use other mechanisms to penalize the manufacturer. However, a lawsuit has since been filed in federal court by drug manufacturers asserting violations of Constitutional law as it relates to interstate commerce. To date, twelve other anti-price gouging bills have been introduced in states, although none have been enacted.

 

Drug Importation

Earlier this year, Vermont became the first state to pass a drug importation bill, allowing the state to import wholesale prescription drugs from Canada for use by all state residents. The law requires the designation of a state agency to become a licensed drug wholesaler, or to contract with a licensed drug wholesaler. Several steps remain before Vermont’s program can go into effect, including the state health department receiving federal approval from HHS by July 2019. In addition, although the Utah legislature failed to pass a bill that would have created a program for importing drugs from Canada, the legislature requested that the Utah Department of Health conduct a feasibility study associated with drug importation.

 

Generic Drugs

Recently, Maine passed a law requiring brand name manufacturers to make samples of drugs available to generic drug manufacturers, with the intention of promoting competition by increasing access of information for companies developing lower-cost generic drugs. The law states that, “In order for there to be competition in the prescription drug market, developers of generic drugs and biosimilar biological products must be able to obtain quantities of the reference listed drug or biological product with which the generic drug or biosimilar biological product is intended to compete.”

 

Pharmacy Benefit Managers

Several states have passed bills regarding pharmacy benefit managers (PBMs), which require increased transparency and disclosure of information on drug rebates and concessions. For example, Nevada passed a law in 2017 requiring PBMs to disclose the amount of rebates received from drugs used to treat diabetes. Connecticut’s drug price transparency law also requires PBMs to provide information on rebates and other price concessions received from drug companies. Mississippi passed a law preventing PBM gag clauses, which stop pharmacists from sharing information with patients on lower-cost drug options.

 

Other State Policies

In Montana, the legislature passed a bill establishing an interagency committee to study state drug pricing and spending trends, which will make recommendations to the state legislature on drug pricing policies in late 2018. In addition, New York implemented an annual cap on drug spending in its Medicaid program. Under the law, if spending projections extend beyond the cap, the state health department must identify the costliest drugs and attempt to negotiate additional rebates with manufacturers. This law also gives the state the authority to develop an independent panel that can penalize manufacturers through various mechanisms.

 

Future Opportunities

Emerging state legislation to address the rising cost of drug prices in demonstrates potential paths forward to address drug prices at the state level. The National Academy of State Health Policy (NASHP) has developed model legislation to address drug price transparency, drug importation, rate setting, and pharmacy benefit managers. The NASHP resource includes model legislation for states, bill text from states that have already passed legislation, and relevant briefing documents.

More States Following AZ's Lead Establishing Overdose Review Teams

More States following AZ’s Lead to Establish Overdose Fatality Review Teams

Overdose fatality reviews allow states to better understand the circumstances surrounding fatal drug overdoses so they can design better interventions.  Review teams can uncover the individual and population factors and characteristics of potential overdose victims. Knowing the who, what, when, where, and how of fatal overdoses provides a better sense of the strategies and coordination needed to prevent future overdoses and results in the better allocation of overdose prevention resources and services.  

Nine states including AZ have set up teams so far. The Network for Public Health Law provides a good overview of the states that have review teams. Here are some of the laws [OK (HB 2798), RI (S 2577 and H 7697), and VA (SB 399)], DE (HB 211) and our own (HB 2038). The laws establishing fatal overdose reviews often include the entity authorized to create and manage the review team or committee, the membership requirements for teams or committees, the scope of work of the teams or committees, confidentiality and liability protections, and data access authorizations.

Webinar: Complying with Arizona's Opioid Related Licensing Requirements

AzHHA Webinar: Creating an AZ Opioid Compliance Program to Meet Licensing Regulations

Keep current with the AZ changes related to opioid prescribing, ordering and administration requirements in the hospital and outpatient clinic settings. AzHHA recently released the Arizona Opioid Compliance Toolkits for Hospitals and Outpatient Clinics. On Tuesday, September 18th, Coppersmith Brockelman, LLC, will present a webinar to review the new legal requirements and recommendations for structuring an opioid compliance program. 

For more information and to register, click here.

Can Medical Marijuana Card Fees Pay for Drug Treatment in AZ?

This week AZ Attorney General Brnovich wrote an Opinion stating that state lawmakers (or presumably the ADHS) can use qualified medical marijuana patient card fees to operate programs to help get people off of other drugs. The Arizona Medical Marijuana Fund (administered by the ADHS) contains more than $44M right now (the fund consists of fees paid by patients for cards, other card fees like dispensary agent cards, and dispensary application fees). 

Here’s a simple Q & A from this week's Opinion:

Q. Could the Legislature, through the budget process, direct the ADHS Director to appropriate some of the Fund monies to help people addicted to drugs?

A. Yes.  The Legislature may direct the ADHS Director to spend Fund monies for programs to help people addicted to drugs if: (1) the appropriation is passed with a three-fourths vote of each legislative chamber; (2) the appropriation does not deplete the Fund and leave insufficient revenues to cover the immediate and future costs of the initiative; and (3) the appropriation furthers the purpose of the AMMA, i.e., it relates, in some way, to medical marijuana.

The AG Opinion states that:

“The Legislature may direct the ADHS Director to expend monies from the Fund for programs to help people addicted to drugs if: 1) the appropriation is passed with a three-fourths vote of each house; 2) the appropriation does not deplete the Fund and leave insufficient revenues to cover the immediate and future costs of the initiative; and 3) the appropriation furthers the purpose of the AMMA.  

To that end, an appropriation for activities related to distinguishing between medical and nonmedical uses of marijuana, protecting patients and providers from criminal prosecution, or carrying out, implementing, or administering the AMMA would meet this criterion.  If these requirements are met, it is not necessary to submit an appropriation request to Arizona’s voters.

Behavioral Health Advocacy Training Institute: Apply Now

The Eric Gilbertson Advocacy Institute for Behavioral Health (aka Institute) is designed for service recipients/participants, family members, Board Members, and individuals concerned about quality behavioral health in Arizona.  The goal of the training is to provide you a comprehensive overview of the Arizona behavioral health system and to assist participants in becoming effective advocates for those receiving behavioral health services.

The Institute provides information, training, and resources to participants on behavioral health issues at the individual, provider, and system level. The Institute will provide participants with opportunities to meet and talk with leaders and advocates in the Arizona behavioral health system.  As a participant, you’ll have an opportunity to meet and unite with others who have a similar interest in creating a powerful voice on important issues. You’ll also learn how various state agencies are responsible for the delivery of behavioral health services and how the legislative process works at the state and national levels to impact behavioral health policy. 

The Training Institute will cover the History of the Disability Movement and the Role of ADHS, ADES, AHCCCS, ADOE, the Courts & Corrections, the Role of the Regional Behavioral Health Authorities (RBHAs) & Complete Care Contractors Community Supports State & Federal Policy Legislative Process Organizing for Change.  The Application deadline is August 15.  For more information visit http://azabc.org/eg_institute/

Substance Abuse Prevention Needs Assessment

AHCCCS is conducting a Statewide Substance Abuse Prevention Needs Assessment to better understand what prevention activities are going on and what the prevention needs in our communities are and about the experiences of folks who work or volunteer in substance abuse prevention. 

If you fit the bill, it would be great if you could take 10 minutes to support this important effort by taking this Arizona Substance Use Prevention Workforce Survey

AzPHA Public Health Policy Update

Save the date

90th annual azpha fall conference and annual meeting

Integrating Care to Improve Public Health Outcomes:

Primary Care | Behavioral Health | Public Health

October 3, 2018 

Desert Willow Conference Center

There’s widespread support for the goals of the Triple Aim: To deliver the highest quality care with an optimal care experience at the lowest appropriate cost. The key is developing systems of care that best achieve these goals. 

Our 90th Annual Fall Conference and Annual Meeting Integrating Care to Improve Public Health Outcomes: Primary Care | Behavioral Health | Public Health will explore efforts currently underway to integrate care and improve outcomes in Arizona as well as initiatives on the horizon to develop systems of care that best achieve the goals of the Triple Aim.

We’ll kick off our Conference with a presentation of the latest academic research that evaluates the outcomes of co-located and integrated models of behavioral care as part of primary care as well as evidence-based toolkits to assist practices including ways to measure progress. We’ll also be exploring how providers are implementing new strategies to integrate care via AHCCCS’ “Targeted Investment” program which provides financial incentives to eligible providers to develop systems for integrated care.

We’ll conduct a short AzPHA Annual Meeting over a delicious buffet lunch followed by our keynote address from the American Public Health Association President Joseph Telfair, DRPH, MSW, MPH.  In our afternoon sessions, we’ll learn about new initiatives to work with managed care in two key areas that impact health outcomes: tobacco use and housing and homelessness.

We’ll close with a panel discussion of key leaders among Arizona’s Managed Care Organizations as they discuss priorities and strategies for improving outcomes under the new integrated Medicaid contracts which will begin October 1, 2018.  The new contracts will require better coordination between providers which can mean better health outcomes for members.

After the conference we'll have a hosted reception as we celebrate AzPHA’s 90th Anniversary!

I’m still working on the agenda, but I expect to have it fleshed out in a couple of weeks and have our registration site up and sponsorship packets out by the 3rd week in June. A summary of the conference is up on our homepage at www.azpha.org.

 

American Cancer Society Changes Colon Cancer Screening Recommendation

The American Cancer Society changed their recommendation for colon cancer screening by moving down the standard recommendation 5 years- suggesting that most people get screened at age 45. There are a couple of ways people can get screened, either using a sensitive test that looks for signs of cancer in a person’s stool or with an exam that looks at the colon and rectum (a colonoscopy).  The reason they changed the recommendation is because new data shows that cases of colorectal cancer for people under age 55 increased 50% between in the last 20 years (1994-2014).

However, just because the recommendation from the ACS changed doesn’t necessarily mean that insurers will begin paying for it between 45 and 49 years old.  For that to happen, the United States Preventive Services Task Force would need to recommend the change and list it as a Category A or B preventive health service.

In recent years, a prevention model of health has woven its way into the fabric of traditional models of care. With the passage of the Affordable Care Act the role preventive services has expanded significantly in the US health care delivery system.  Preventive health care services prevent diseases and illnesses from happening in the first place rather than treating them after they happen.

Category A & B” preventive services recommended by the United States Preventive Services Task Force  are now included (at no cost to consumers) in all Qualified Health Plans offered on the Marketplace. In addition, many employer-based and government-sponsored health plans have included Category A & B preventive services in the health insurance plans they offer to their respective members.

Currently, the United States Preventive Services Task Force recommends 49 Category A & B Preventive Health Services that include screening tests, counseling, immunizations, and preventive medications for adults, adolescents, and children.  The Task Force consists of a panel of experts representing public health, primary care, family medicine, and academia.  They update the list of recommended services by reviewing best practices research conducted across a wide range of disciplines.

You can also browse the USPHS website and check out the preventive services that they have evaluated but don’t recommend. Most of the services are broken down by age, gender and other risk factors.

 

Medicaid Program Scorecard Released by Feds

The Centers for Medicare & Medicaid Services released a new Medicaid program scorecard this week.  It includes some quality metrics along with federally reported measures in a Scorecard format.

The data that’s built into the state by state scorecard only uses information that states voluntarily submit.  There are 3 main categories (state health system performance; state administrative accountability; and federal administrative accountability) and lots of subcategories.

The most interesting part of the Scorecard I think are the State Health System Performance Measures portion.  Some of the subcategories that are reported in that category on a state by state basis are things like well child visits, mental health conditions, children’s preventive dental services and vaccination rates, and other chronic health conditions.

It looks like a good and valuable tool that will (if they continue to populate the scorecard) provide more transparency into the effectiveness of state Medicaid programs over time. The data that are submitted are voluntary - not compulsory - so that hurts the number of measures that states turn in.  It might be something that you’ll want to bookmark for reference in the future.

 

Federal “Right to Try” Law Passed and Signed

Congress passed and the President signed a new law this week that gives people with a terminal illness new options for treatment by allowing those folks a way to independently seek drugs that are still experimental and not fully approved by the US Food and Drug Administration.

The new law basically gives terminally ill patients the right to seek drug treatments that remain in clinical trials and "have passed Phase 1 of the FDA’s but haven’t been fully approved by the FDA.  

Arizona voters have already approved a similar law (by a wide margin).  In 2014 AZ voters approved Proposition 303  (referred to the ballot by the Legislature) that makes investigational drugs, biological products or devices available to eligible terminally ill patients. The AZ law has uses the same definition of an "investigational" drug that the new federal law uses.

 

Western Region Public Health Training Center Grant Renewed

The Western Region Public Health Training Center was awarded a renewed grant as a center for the Regional Public Health Training Centers Program.  They’ll continue to be housed in the University of Arizona Mel and Enid Zuckerman College of Public Health and we will continue to assess the training needs and strengthen the skills of the public health workforce with their partners in Arizona, California, Hawaii, Nevada, and the Pacific Islands.

The training center has literally hundreds of trainings that focus on all sorts of health professionals and the public health workforce.  So no matter what your public health workforce training needs are – the thing to do first is to check the centers website to see if they have the course that you need.  Most likely they will.

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I’m doing my best to populate the “upcoming events” part of our AzPHA website.  If you have an upcoming public health related event- please let me know and I’ll get it up on our website at: http://www.azpha.org/upcoming-events/