Opioids

AZ Develops Pain & Addiction Curriculum for Clinicians

It's no secret that getting a public health handle on the opioid crisis will take a multi-pronged effort for an extended period.  Part of the solution was the policy development, passage and implementation of the Arizona Opioid Epidemic Act.  Other elements include developing and implementing new Opioid Prescribing Guidelines and developing new regulations for pain management clinics.

Another huge element is changing the culture of pain and addiction care.  ADHS has completed a Arizona Pain and Addiction Curriculum that approaches pain and addiction in a new way - as complex, interrelated, public-health issues. 

The curriculum was jointly developed by Deans and Curriculum Representatives from every MD, DO, NP, PA, ND, DMD and DPM program in Arizona.  The program stresses not only the new evidence base of pain and addiction care.

Resources for programs consist of both a Pain and Addiction Curriculum and a Pain and Addiction Faculty Guide.  Because it was created and facilitated by public health, it’s accessible online at any time, to the appreciation of other teaching programs across the country.

Kudos to ADHS and the dozens of stakeholders for this novel work and especially AzPHA member Lisa Villarroel MD.  Work on this scale hasn’t been done before in the US - so kudos to our Arizona teaching programs for being so open and collaborative. This is another example of the stakeholder driven innovative work being done right here in Arizona that's likely to be adopted as a best practice in other states.

New Federal Opioid Intervention Becomes Law

A couple weeks ago congress passed and the president signed the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act. Much like Arizona’s Arizona Opioid Epidemic Act – approval of the bill was bipartisan, with a House vote of 393-8 and 98-1 in the Senate.

The final bill creates, expands and reauthorizes programs and policies across several federal agencies, and focuses on prevention, treatment and recovery. The text of the Act is extremely long, but you can view a high level summary on this landing page.

Some of the provisions are in line with recommendations in the 2017 ADHS Opioid Response Report like calling for changing an old federal regulation that prohibited Medicaid from covering patients with substance abuse disorders who were getting treatment in a mental health facility with more than 16 beds. The effect of the former law limited the number of beds available for low-income patients suffering from addiction- so hopefully the network of treatment facilities will expand as a result of this change in the law. The new federal law allows for 30 days of residential treatment coverage.

The new law allows nurse practitioners and physician assistants to prescribe buprenorphine, which is an anti-addiction medication that requires a special license and extra training.  For the next 5 years, it will also allow nurse anesthetists, nurse midwives and clinical nurse specialists to prescribe buprenorphine.  Right now, only about 5% of doctors are licensed to prescribe it.  It’ll take time for the inventory of prescribers to increase because of the training that’s required- but over time this provision will help network capacity especially in rural areas.

The Act also creates a grant program for comprehensive recovery centers that include housing and job training, as well as mental and physical health care. It will also increase access to medication-assisted treatment.

Some aspects of that law that relate to Medicaid include:

  • Temporarily requires coverage of medication-assisted treatment under Medicaid;

  • Prohibiting the termination of Medicaid eligibility for juveniles who are inmates of public institutions;

  • Requiring CMS to establish a demonstration project to increase provider treatment capacity for substance-use disorders;

  • Requiring state Medicaid programs to establish drug management programs and drug-review and utilization requirements for at-risk members; and

  • Extending enhanced federal matching rate for expenditures regarding substance-use disorder health-home services under Medicaid.

Interestingly, the bill includes a provision to help stop the flow of black-market opioids into the country by mail, especially synthetic fentanyl and its analogs.  The US Postal Service will need to provide the name and address of the sender and the contents of at least 70% percent of all international packages, and 100% of packages from China.

All international shipments will need to have the name and address of the sender by the end of 2020.  The Postal Service was also given the authority to block or destroy shipments for which the information isn’t provided.

The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act is long and comprehensive so I can’t cover everything….  But the bottom line is that public health policy – both here in AZ and now nationally is beginning to address the epidemic.

US Senate Proposes Opioid Crisis Response Act

Last week the US Senate released the Opioid Crisis Response Act of 2018, a bipartisan package to address the opioid epidemic. The Act authorizes funding to expand prevention, research, treatment, and recovery programs- but even if it passes as-is, it would still need to go through the actual appropriations process.

The Senate is expected to vote on the Bill soon without the opportunity for amendments and it’s expected to be approved on a broad bipartisan basis (much like the Arizona Opioid Epidemic Act was). But, after that, it’s unclear whether the House will vote on this version or the Bill or move to conference the Opioid Crisis Response Act with the recently House-approved “SUPPORT for Patients and Communities Act (H.R.6)”.  Here’s a summary of what’s in the bill as it sits today:

Medicaid 

  • Clarifies flexibilities around Medicaid’s "Institutions for Mental Disease" (IMD) exclusion where in some cases managed care plans may provide alternative services in lieu of other services that are not permitted under the state plan. 

  • Modifies IMD exclusion for pregnant and postpartum women to address a subset of the prohibition on Medicaid from paying for otherwise coverable services for certain adults while in institutions for mental disease. 

  • Codifies regulations permitting managed care plans to cover treatment in an IMD facility for a certain number of days in a month in lieu of other types of services.

  • Clarifies states’ ability under Medicaid to provide care for infants with neonatal abstinence syndrome (NAS) in residential pediatric recovery centers.

  • Directs CMS to issue guidance to states on options for providing services via telehealth that address substance use disorders under Medicaid.

  • Directs CMS to issue guidance on states’ options for treating and managing pain through non-opioid pain treatment and management options.

  • Clarifies states’ ability to access and share data from prescription drug monitoring program databases consistent with the parameters established in state law.

  • Directs HHS to provide technical assistance to states to develop and coordinate housing-related supports and services under Medicaid, either through state plans or waivers, and care coordination services for Medicaid enrollees with substance use disorders. 

Prevention

  • Authorizes CDC’s work to combat the opioid crisis through the collection, analysis, and dissemination of data, including through grants for states, localities, and tribes.

  • Authorizes funding through CDC from FY19 - FY24 for states to improve their prescription drug monitoring programs and implement other evidence-based strategies.

  • Authorizes funding from FY19 - FY21 for CDC to support states’ efforts to collect and report data on adverse childhood experiences through existing public health surveys.

  • Authorizes a HHS grant program through 2026 to allow states to develop, maintain, or improve prescription drug monitoring programs and improve their with other states and with other health information technology.

  • Authorizes data collection and analysis through 2023 on neonatal abstinence syndrome or other outcomes related to prenatal substance abuse and misuse, including prenatal opioid abuse and misuse. 

  • Creates an interagency task force to make recommendations regarding best practices to identify, prevent, and mitigate the effects of trauma on infants, children, youth, and their families.

 

Treatment and Recovery

  • Allows physicians who have recently graduated in good standing from medical schools to prescribe medication-assisted treatment (MAT).

  • Authorizes a grant program from FY19-FY23 to support development of curriculum that will help healthcare practitioners obtain a waiver to prescribe MAT.

  • Codifies the ability of qualified physicians to prescribe MAT for up to 275 patients if the practitioner meets certain requirements. 

  • Authorizes a grant program from FY19 - FY23 through SAMHSA for entities to establish or operate comprehensive opioid recovery centers that serve as a resource for the community.

  • Requires HHS to issue best practices for emergency treatment of known or suspected drug overdose, use of recovery coaches after a non-fatal overdose, coordination and continuation of care, and treatment after an overdose and provision of overdose reversal medication as appropriate.

  • Requires HHS to provide technical assistance to hospitals and other acute care settings on alternatives to opioids for pain management and authorizes a grant program to support hospitals and other acute care settings that manage pain with alternatives to opioids. 


Some of these policy measures were also recommended in the ADHS' set of federal policy recommendations in their 2017 report.  Sadly, nothing in here directs HHS to drop its policy of not funding syringe access but all in all this Senate bill looks like it's pretty good public health policy.  Nice to see.

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.

New AZ Public Health Laws Take Effect Friday

State legislators passed several new laws that will influence public health last session- but almost all of them won’t take effect until Friday (August 3). The Legislature has developed a report that report that summarizes all of this year’s bills. The health-related bills are on pages 99-108.  Here’s a snapshot:

  • HB 2088 will require school districts to: 1) develop intervention strategies to prevent heat-related illnesses, sudden cardiac death, and prescription opioid use; 2) notify parents when kids are bullied; and 3) tell parents if a student is suspected of having a concussion.  An ADHS concussion training & management report is due at the end of 2018.

  • HB 2196 will limit ambulance certificate of necessity (CON) hearings to 10 days unless the Administrative Law Judge determines that there’s an extraordinary need for more hearing days.  Hearings had previously gone on for many weeks or even months.

  • HB 2197 requires AZ health licensing boards to collect certain data from applicants (beginning January 2020).

  • HB 2228 directs AHCCCS to exempt tribal members from work requirement waiver requests (more on this later in the update).

  • HB2235 will set up a new licensed class of dental professionals called a Dental Therapist.  The next step is for the AZ Board of Dental Examiners to develop the scope of practice and license regulations.

  • HB 2323 authorizes contracted nurses to provide emergency inhaler medication in case of respiratory emergencies (takes effect this semester).

  • HB 2324 charges the ADHS with implementing a voluntary certification for Community Health Workers. The next steps are for the ADHS to establish the advisory committee and begin the Rulemaking to set up the certification process.

  • HB2371 sets up statewide licensure for food trucks. The licenses will have reciprocity in all county health and environmental service departments.

  • SB 1083 will require public schools (K-3) to have at least 2 recess periods beginning this semester.   Grades 4 and 5 will be required to have 2 recess periods beginning August 2019.

  • SB 1245 will develop a produce incentive program within the Supplemental Nutrition Assistance Program within ADES.

  • SB 1389 requires the ADHS to develop an HIV Action Plan.

  • SB 1465 requires the ADHS to adopt rules and license sober living homes.  It also allows them to contract with a third party to assist with licensure and inspections. They have a 2-year exemption from the regular rulemaking process.

  • Note: SB 1001 - The Arizona Opioid Epidemic Act was in a Special Session and became law several months ago. 

CHW Rulemaking, Opioid Epidemic Ends and Various CEU Opportunities

Community Health Worker Certification Rulemaking

The new law that authorizes the voluntary certification of community health workers will officially take effect on August 3 (HB 2324 Voluntary Certification for Community Health Workers). Voluntary certification can’t begin until the ADHS completes their Administrative Rulemaking (regulations) that’ll flesh out the details of the certification program including defining the core competencies, the criteria for establishing those competencies, continuing education requirements, the fee and other certification details. 

The first step in the Rulemaking process is for the ADHS to populate the 9 member advisory council to help inform the Rulemaking (the ADHS Director makes those appointments based on the criteria in the Session Law - the language at the end of the bill here).  After that, the agency needs to open the docket for the rulemaking and put draft rules out for public comment in what’s called the Arizona Administrative Register.

The public will then have a chance to comment on those initial draft regulations.  The ADHS will then consider those comments and file the final proposed rules with the AZ Secretary of State (here’s a summary of the rulemaking process on the SOS website).

Before the rules become effective- the agency needs to get final approval of the regulations by the Governor's Regulatory Review Council (GRRC).  If GRRC approves the rules- they’d become effective and voluntary certification could begin.

Realistically- even if the ADHS starts right away and appoints the advisory council and they begin meeting this Summer and began writing the initial draft rules later this year, it could easily take a couple of years before they’d become effective- so it's important to begin the process soon with initial advisory council meetings. 

You might be familiar with other agency rulemaking that have gone a lot faster than this.  That’s likely because those were probably “exempt” rulemakings, which provides several rulemaking short cuts including an exemption from the GRRC requirements.  Sadly, the CHW Rulemaking isn’t “exempt”.

The Rulemaking will be among the topics we’ll all be talking about at the AZCHOW Conference on June 21st and 22nd in Tucson.  Hopefully many of you will be able to make it.  AzPHA will be exhibiting at the conference.

 

Opioid Public Health Emergency Executive Order Ends

This week the Governor officially ended the emergency public health declaration that was signed via an Executive Order about a year ago.  Much has been accomplished over the last year including implementing legislation that improves prescribing practices and enhances emergency responses and increases access to treatment.  Of course- the work will go on.  The epidemic didn’t start overnight, and it surely won’t end overnight.  You can read the official end of the emergency declaration here.

Rep. McSally (R) is hosting a House of Representatives Border and Maritime Subcommittee hearing today (May 30) at 9:30 am at the UA College of Medicine Phoenix (Building 2) entitled: “An Unsecure Border and the Opioid Crisis: The Urgent Need for Action to Save Lives” featuring the Governor, various federal officials from the DEA, CBP, and DHS as well as Dr. Christ, Debbie Moak, and some people from faith-based organizations. You can see the panel line up here.  It looks like it’s an open meeting.

 

Aligning Health and Early Childhood Learning

Evidence shows how important early childhood education is in protecting people from disease and disability as an adult-  and that a child’s health impacts his or her ability to learn and succeed in school and later in life. Even with these known positive connections between early learning and wellness- health and education systems sometimes fail to align and provide opportunities to maximize health and early learning outcomes for children.

To address the disconnect between health and education, the HHS & US Department of Education outlined a set of recommendations for states and communities to align health and early learning systems. The recommendations emphasize the need for a comprehensive, seamless, and coordinated set of systems to support children, parents, and families.

 

Legislative Session Webinar Posted

The UA has posted my webinar from a couple of weeks ago that summarizes the legislative session from a public health perspective.  The whole thing is about an hour long.  You can check out the webinar on the UA Telemedicine Website.  Here’s the PowerPoint that I used.

 

CDC’s Learning Connection

The CDC has what they call a “Learning Connection” which connects public health professionals, including healthcare workers, to training opportunities and educational tools developed by CDC. Their Learning Connection also engages public health professionals around the world via social media messaging and a monthly e-newsletter.

The CDC Learning Connection: 1) features quality learning opportunities from CDC, other federal agencies, and federally funded partners; 2) keeps you up-to-date on the latest training through a free monthly e-newsletter; 3) offers access to thousands of training opportunities through CDC TRAIN — CDC’s online learning system; 4) connects you to information about CDC internships and fellowships; and 5) makes it easy to locate courses that offer continuing education. There are literally hundreds of courses one can take- mostly on-line and self-paced.

 

Free Continuing Education from MMWR and Medscape:

CDC MMWR and Medscape introduced a new FREE continuing education (CE) activity that describe trends and demographic differences in health outcomes and healthcare use for childhood asthma, based on a CDC analysis of asthma data from the 2001-2016 National Health Interview Survey for children 17 years and younger.

This activity is intended for pediatricians, pulmonologists, public health officials, nurses, and other clinicians caring for patients with childhood asthma. To access this FREE MMWR / Medscape CE activity visit https://www.cdc.gov/mmwr/cme/medscape_cme.html. If you’re not a registered user on Medscape, you may register for free or login without a password and get unlimited access to all continuing education activities and other Medscape features.

 

Free Continuing Education Training for Opioid Prescribers offered by UA

With the requirement of Arizona prescribers to complete 3 hours of opioid, substance use disorder, or addiction-related CME, the University if Arizona’s Center for Rural Health we offer Arizona based materials and continuing education opportunities including:

Free online CME vouchers worth $150: order vouchers by responding to this email. We can mail them to you in batches of 100 to 500. Please feel free to forward the listserv blast below and attached documents for your attendees.

Free Arizona Opioid Prescribing Guidelines printed copies: order at http://www.azdhs.gov/audiences/clinicians/index.php#clinical-guidelines-and-rx-guidelines-order

________

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/

 

Dr. Bob’s Travelogue

I’ve gotten a couple more Travelogues from Dr. Bob in the last couple of weeks.  He’s been living for the last couple of months just outside of London. He's writing some entertaining travelogues- with a splash of public health of course. Take a few minutes when you're on a comfortable couch and enjoy Travelogue 1 & 2: Getting Settled and Travelogue 3: Nutrition. Here’s Interlude from last week and this new one Hoof Beats.

AzPHA Public Health Policy Update: January 30, 2018

Special Session Produces Opioid Intervention Product

Last week’s Special Session of the Legislature produced a robust new law that includes a host of new interventions to address Arizona’s opioid epidemic.  Here’s a link to the official document that describes the final new law.

Various pieces go into effect at different times, so all the provisions won’t be implemented all at once.  Some things have an expiration date.  For example, the Good Samaritan component of the law expires on July 1, 2023.

The new law has over 90 provisions that impact prescribing and dispensing practices, criminal prosecution, drug drop off locations, educational programs and a new fund to assist with treatment.  If you’re interested, the best thing is to examine it in detail.

This was a textbook example of solid public health policy development that included enhanced surveillance and analysis, a literature review, research of best practices, stakeholder input, and bipartisan consultation that resulted in a consensus bill.  It’s not perfect (for example it doesn’t decriminalize needle exchange) but it’s a testament to good public policy-making.

 

New Bills this Week

Before we get to the committee agendas for this week- here are a couple of new bills that were proposed.  AzPHA supports both of them.

SB 1445 AHCCCS Dental care, pregnant women

This is a priority Bill for AzPHA.  It would provide oral health coverage for pregnant women who receive their health insurance coverage through AHCCCS.  The benefit would be limited to $1000 and could be used for other than emergency dental procedures (beginning October 1, 2017 all adult Medicaid members became eligible for up to $1000 in emergency dental services per year).  Lots of good public health reasons to support this one.

HB 2443  Medical services purchase, premiums

The Bill would essentially allow Arizonans that don’t normally qualify for Medicaid to buy Medicaid health insurance.  It would ask AHCCCS to write the rules and regulations for the program including setting a premium that ensures people buying in would pay full freight.  If approved, it would allow people to buy in beginning on October 1, 2019.  The bill is also contingent on CMS approval.

 

Committee Hearings this Week

Now that the Special Session is finished, the various House and Senate committees are back in full swing.  Several of the priority public health bills that we’re following are progressing through the system. 

Below is a summary of the committee hearings… I’ve pasted a quick summary of the Bills that are being heard this week.  After that is a listing of the other bills that haven’t been heard in their committees yet.

Remember to stay engaged and voice your opinion via the www.azleg.gov commenting system. I gave a summary of how to sign up for the system in my policy update 2 weeks ago.

Tuesday

House Commerce, Tuesday, 1/30 @ 2 pm, HHR 1

HB 2064 Medical marijuana; packaging; labeling              

This Bill proposes that medical marijuana dispensaries be prohibited from selling a marijuana product that’s packaged or labeled in a manner that’s "attractive to minors". Due to voter protection, this legislation requires the affirmative vote of at least 3/4 of the members of each house of the Legislature for passage.  We’re supporting this bill.

 

Wednesday

Senate Government, Wednesday, 1/31 @ 2 pm, SHR 109

SB 1420 medical marijuana; inspection; testing; appropriation

This Bill would require the ADHS to set up testing standards for medical marijuana and begin enforcing the standards beginning in 2019.  We’re supporting this legislation.

 

House Judiciary & Public Safety, Wednesday, 1/31 @ 2 pm HHR 4

HB 2038 Drug overdose review teams; records                

Under this proposed Bill, law enforcement agencies would be required to provide unredacted reports to the chairperson of a local Drug Overdose Fatality Review Team on request.  All information and records acquired by a Team are confidential and not subject to subpoena, discovery or introduction into evidence in a civil or criminal proceeding or disciplinary action.  We’re signed up in support of this one.

Thursday

House Health, Thursday, 2/1 @ 9 am, HHR 4

HB 2084 Indoor tanning; minors; restricted use

Under this proposal, tanning facility operators would be prohibited from allowing a person under 18 years of age to use a "tanning device". Tanning facilities are prohibited from advertising or distributing promotional materials that claim that using a tanning device is free from risk or will result in medical or health benefits. We’ve signed on in support of this.

HB 2109 Tobacco possession; sale; age; signage                

This Bill would prohibit furnishing a tobacco product to a person who is under 21 years of age. The definition of "tobacco product" is expanded to include "electronic smoking devices". We’ve signed up in support of this bill.

HB 2197 Health professions, workforce data

This Bill would require AZ health licensing boards to collect certain data from applicants (beginning January 2020) to get better data about health professions workforce distribution and needs.  The data would be confidential.

HB 2228 Annual waiver, applicability

This Bill would direct AHCCCS to exempt tribes from their directed waiver requests to CMS asking permission to implement work requirements for some Medicaid members.  The recently submitted Waiver request includes an exemption for American Indians, however, this would place the exemption into statute.

HB 2324 Community health workers; voluntary certification

This Bill is a top priority for us. It would charge the ADHS with developing a voluntary certification program for community health workers.  The Department rulemaking would include certification standards including qualifications, core competencies, and continuing education requirements. We’ve signed up in support of this bill. 

 

Public Health Related Bills Waiting in the Wings

House Bills

HB 2071 Rear-facing car seats         

This Bill would require kids under 2 years old to be in a rear-facing restraint system unless the child weights at least 40 pounds or is at least 40 inches tall.  We’ve signed up in support of this bill.  This Bill cleared the House Transportation & Infrastructure Committee last Wednesday.

HB 2208 Prohibition, photo enforcement

This Bill would prohibit cities and other jurisdictions from having photo enforcement of red light and speeding violations.  While nobody likes getting a ticket in the mail, the data suggest that photo enforcement saves lives and prevents injuries (especially red light photo enforcement).  We’ve signed up in opposition to the bill.  This Bill cleared the House Judiciary and Public Safety Committee last week.

HB 2127 Children's health insurance program

This Bill removes the trigger that automatically freezes the KidsCare program if FMAP (the federal contribution) drops below 100%.  It allows the state to freeze it if costs are more than the state or federal allotment. The bill does not require the state to appropriate any money for a state share. 

We’ve signed up in support of this bill because it provides a pathway to keep KidsCare if the federal government drops its contribution level.  This one cleared the House Health Committee a couple of weeks ago.

HB 2389  Syringe access programs; authorization

Under this Bill, organizations in Arizona may establish and operate a needle exchange program.  Persons, employees and volunteers operating within the scope of the law may not be charged or prosecuted for their activities. It’s currently a felony to distribute needles to illegal drug users.

We’ve signed up in support of this bill because this type of program is evidence-based and reduces the spread of bloodborne diseases as well as engaging in intravenous drug users into treatment. No hearings scheduled yet.

 

HB 2222 Feminine hygiene products, requirements

This Bill would require the Arizona Department of Corrections to offer female inmates an unlimited supply of feminine hygiene products free of charge. We signed up in support.

 

Senate Bills

SB 1007  Motorcycle operation; riding between lanes          

Under this proposal, motorcycle operators would no longer be prohibited from passing in the same lane occupied by the vehicle being overtaken and from operating a motorcycle between the lanes of traffic if they’re wearing a helmet.  We decided to take a position against this one in our Public Health Policy Committee last week.

SB 1022    DHS; homemade food products            

Under this Bill, ADHS would be required to establish an online registry of food preparers that are authorized to prepare "cottage food products" for commercial purposes. Registered food preparers would be required to renew the registration every three years. This is a sensible addition to the current cottage industry food law and we’ve signed up in support.

SB 1083 Schools; recess periods

Under this Bill, district and charter schools would be required to provide at least 2 recess periods during the school day for pupils in grades K-5.  We’ve signed in support of this bill.

SB 1245 Snap Benefit Match

This Bill would appropriate $400K to ADES to develop the infrastructure for a produce incentive program within the Supplemental Nutrition Assistance Program (SNAP) for members to buy Arizona-grown fruits and vegetables.  It would also provide matching funds to SNAP-authorized vendors as an incentive to participate in the fruits and vegetable program.  We’ve signed up in support of this Bill.  It hasn’t been scheduled for a committee hearing yet.

SB 1250 Food Producers, Ordinances

This Bill would make it clear that cities, towns and counties can’t restrict food producers including community gardens from producing food products with some exceptions and inspection authority.

Thanks... and check out our upcoming Spring Conference "Together for Tomorrow: Protecting Arizona's Children at www.azpha.org.

 

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AzPHA Public Health Policy Update: January 24, 2018

Opioid Special Session this Week

The Governor called a Special Session of the Legislature this week to facilitate the passage of a series of statutory changes to address Arizona’s Opioid epidemic. The Bill (called HB 2001 in the House) tackles a wide range of issues as identified in ADHS’ September 5 report.  Some of the interventions include:

  • Limiting the first-fill of opioid prescriptions to 5 days for opioid naïve patients and limiting dosage levels to align with federal prescribing guidelines (exemptions are included for cancer, trauma or burn patients, hospice or end-of-life patients, and those receiving medication assisted treatment for substance use disorder);
  • Expanding access to Naloxone for law enforcement or corrections officers;
  • Increasing oversight mechanisms, and enacting criminal penalties for manufacturers who defraud the public about their products;
  • Enhancing continuing medical education for all professions that prescribe or dispense opioids;
  • Enacting a Good Samaritan law to allow people to call 911 for a potential opioid overdose;
  • Requiring e-prescribing;
  • Requiring all pharmacists to check the Controlled Substances Prescription Monitoring Program prior to dispensing an opioid or benzodiazepine; and
  • Identifying gaps in and improving access to treatment, including for uninsured or underinsured Arizonans, with a new $10 million investment.

The Bill is moving rapidly and received a pass recommendation from the House Health Committee on Tuesday. The expedited process and the Stakeholder meetings that were included during its development will likely result in quick passage and approval. AzPHA has signed up in support of the measure.

 

AHCCCS Proposes Ending “Prior Quarter Coverage”

Under Medicaid law, states are required to provide coverage beginning 3 months prior to the person’s application if the person would have been eligible during those months. Medicaid covers unpaid medical bills incurred during that time. 

The retroactive coverage ensures that enrollees aren't hit with medical bills for the 3 months before they applied for Medicaid if their income was so low that they would have been Medicaid eligible. It also provides an incentive for doctors and hospitals to treat uninsured Medicaid eligible people because they’ll be paid for the services once the person is enrolled. 

AHCCCS is proposing a Prior Quarter Coverage Waiver Amendment asking CMS’ permission to stop covering “prior quarter” coverage. The public has until February 25 to comment on the proposal.  Written comments can be sent to publicinput@azahcccs.gov.

You may want to think about framing your comments by urging CMS to require a 6 month or 1-year limit on the waiver and make final approval conditional upon an evaluation of the impact on hospitals' and community providers' uncompensated care burden as well as the effect on consumer medical debt and gaps in coverage prior to enrollment.

 

Federal Budget Deal Includes CHIP

The (temporary) federal budget bill that was passed and signed this week included a 6-year extension of the federal Children’s Health Insurance Program (called KidsCare in AZ).

Importantly, the federal contribution rate of 100% will stay in place until October 1, 2019.  When AZ approved the KidsCare program a couple of years ago- it was contingent on the fed’s continuing to pay 100% of the costs for the program. Under the current statute, if the federal contribution drops the program would be automatically frozen.

HB 2127 would remove the trigger that automatically freezes the KidsCare program if FMAP (the federal contribution) drops below 100% and allow the state to freeze it if costs are more than the state or federal allotment. We’ve signed up in support of this bill because it provides a pathway to keep Kids Care if the federal government drops its contribution level.  This will be heard in House Health on Thursday.

 

AZ Legislative Update

Last week I covered the Bills relating to public health that had been proposed as of last week.  Here are the new bills from this week:

 

SB 1245 Snap Benefit Match

This bill would appropriate $400K to ADES to develop the infrastructure for a produce incentive program within the Supplemental Nutrition Assistance Program (SNAP) for members to buy Arizona-grown fruits and vegetables.  It would also provide matching funds to SNAP-authorized vendors as an incentive to participate in the fruits and vegetable program.  We’ve signed up in support of this Bill.  It hasn’t been scheduled for a committee hearing yet.

 

SB 1250 Food Producers, Ordinances

This bill would make it clear that cities, towns and counties can’t restrict food producers (including community gardens) from producing food products with some exceptions and including inspection authority. 

 

HB 2208 Photo Enforcement

This bill would prohibit cities and other jurisdictions from having photo enforcement for red light running and speeding.  While nobody likes getting a ticket in the mail, the data suggest that photo enforcement saves lives and prevents injuries (especially photo red lights).  We’ve signed up in opposition to the bill.  SB 2208 will be heard in the House Judiciary and Public Safety Committee on Wednesday afternoon.

 

Bills Being Heard in Committee this Week

 

HB 2324 Community Health Workers; Voluntary Certification

This Bill (which is a priority for AzPHA) is being heard in the House Health Committee on Thursday, January 25.  It would charge the ADHS with developing a voluntary certification program for community health workers.  The Department rulemaking would include certification standards including qualifications, core competencies, and continuing education requirements. We’ve signed up in support of this bill.

 

HB 2084 Indoor tanning; minors; restricted use

This Bill will be heard in the House Health Committee on Thursday.   Tanning facility operators would be prohibited from allowing a person under 18 years of age to use a "tanning device". Tanning facilities are prohibited from advertising or distributing promotional materials that claim that using a tanning device is free from risk or will result in medical or health benefits. We’ve signed on in support of this.

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Yuma County Gets Grant to Combat Childhood Poverty

The National Association of Counties has selected Yuma County to be part of the Rural Impact County Challenge: National Effort to Combat Childhood Poverty.  The program is a partnership between the National Association of Counties and the Robert Woods Johnson Foundation’s County Health Ranking and Roadmaps Program.  

Yuma County is part of a cohort of 11 communities selected nationwide to participate.  A link to the program can be found here: http://www.naco.org/resources/programs-and-services/rural-impact-county-challenge-national-effort-combat-rural-child.

AzPHA Public Health Policy Update: November 9

AzRHA & AzPHA Webinar Tomorrow RE 2018 Legislative Session

Tomorrow we’ll be participating in a joint webinar regarding next year’s legislative session entitled: "Anticipating 2018!!! Arizona’s Fifty-Fourth State Legislature".  It's organized by the Arizona Rural Health Association in cooperation with AzPHA and the UA’s Telemedicine Program. You can tune in from 1-2:30 pm Thursday by visiting https://streaming.biocom.arizona.edu/event/?id=27824.

More information is on AzRHA's website www.azrhassociation.org or by contacting Claudia Gonzalez at cgonzalez@rcbh.edu.

 

National Opioid Commission Recommendations

Last week the President’s Commission on Combating Drug Addiction and the Opioid Crisis released its final report setting out 56 recommendations for addressing the national opioid crisis. The recommendations address issues like federal funding and programs, opioid addiction prevention like prescribing guidelines, prescription drug monitoring programs, and supply reduction and overdose reversal.

You’ll remember that the Acting Secretary for HHS declared that the national opioid epidemic is a Public Health Emergency. Here’s the Secretary’s one sentence declaration.  Presumably some of the recommendations from last week’s final report will make their way into the various HHS agency policies (e.g. CMS). The report is quite long so I didn’t have time to read it all - but this did catch my eye:

"A key contributor to the opioid epidemic has been the excess prescribing of opioids for common pain complaints and for postsurgical pain. Although in some conditions, behavioral programs, acupuncture, surgery, as well as FDA-approved multimodal pain strategies have been proven to reduce the use of opioids, while providing effective pain management, current CMS reimbursement policies create barriers to the adoption of these strategies. In the third Commission meeting, the Commission heard about the need for proper reimbursement of non-opioid pain medications to increase uptake among healthcare providers and limit the use of opioids."

 

Free Online CME Credits for Arizona Prescribers

There’s increasing evidence that opioid medications are over-prescribed and poorly managed because prescribers aren’t aware of appropriate opioid risk management strategies and non-opioid approaches to treating chronic pain. A new and free Continuing Medical Education course is now available to familiarize prescribers with current guidelines for opioid use and prescribing & educate prescribers about non-opioid strategies for pain management.

Opioid Prescribing CME Courses: Responding to the Public Health Emergency Available Online at:  http://www.vlh.com/AZPrescribing/

Learning Objectives:

  • Manage acute and chronic back pain
  • Assess the functional effects of pain in patients.
  • Appropriately utilize a range of therapeutic options when managing patients with chronic pain.
  • Comply with current opioid risk-management practices, including the use of pain contracts and urine drug testing.
  • Educate patients on the proper use, storage, and disposal of opioid medications.

Cost: FREE for Arizona Prescribers   

Arizona Prescribers Registration:  http://www.vlh.com/AZPrescribing/

Supported by a grant through the Governor’s Office for Children, Youth and Families. Developed in Partnership with Arizona Prescription Drug Misuse & Abuse Initiative, University of Arizona College of Public Health, University of Arizona College of Medicine & ADHS.

 

Information about HHS’ Proposed Rules RE: Marketplace Insurance

HHS published an annual set of proposed rules for the Affordable Care Act marketplaces on October 27. Called the “Notice of Benefit and Payment Parameters,” the rules set out expectations for insurers and the states that regulate them.  

It's a really long proposed Rule and I haven’t been able to find the time to analyze it all (nor am I really capable of doing a detailed analysis) but I found a pretty good summary regarding the proposals.  The proposed Rule changes focus on: 1) Essential Health Benefits; 2) Qualifying Health Plan Certification Standards; 3) Rate Reviews; 4) Medical Loss Ratios; and 5) Risk Adjustment.

 

New Bulletins from CMS about Waiver Reviews & Approvals

Last week CMS released two information bulletins outlining activities they say they’ll undertake to improve the transparency and efficiency of the various processes for Medicaid Waivers and State Plan Amendment review and approvals. The 2 bulletins are procedural commitments to move waivers and SPAs more quickly through the review and approval process.

The “State Plan Amendment and 1915 Waiver Process Improvements to Improve Transparency and Efficiency and Reduce Burden” bulletin and the “Section 1115 Demonstration Process Improvements” bulletin are both online at https://www.medicaid.gov/federal-policy-guidance/federal-policy-guidance.html

 

First Things First Parent Kit

From the day a child is born, the care, attention, love and support they experience lays the foundation for their future. The First Things First Parent Kit is online to help you meet the challenges of being a parent and do your best in supporting the healthy development of your baby, toddler or preschooler.

You'll find information and resources on child development, health and safety, quality child care and school readiness:  Go to the Parent Kit.