Medicaid

Aligning the Roles of Medicaid and Public Health

Aligning the Roles of Medicaid and Public Health

Medicaid and public health partnerships play an important role in advancing a statewide approach to improving health and reducing health disparities. Collaboration and shared priorities between agencies can play a super important role in improving outcomes.

The Association of State and Territorial Health Officials recently put together this interesting and easy to listen to 30 minute podcast that highlights opportunities to  leverage each agency's respective roles and resources through the CDC’s 6|18 Initiative.  Here are some links to additional resources regarding these kinds of partnerships:

National Medicaid Performance Measures for Kids Released

Medicaid and the Children’s Health Insurance Program serve nearly 46 million children which is 33% of the kids in the US- which means that these programs are a huge leverage point for improving health outcomes.  Measuring the effectiveness of these programs is critical to improving their performance and in providing the information needed to design policy interventions.

The Centers for Medicare & Medicaid Services plays a key role in promoting quality health care and as part of their accountability standards they have a core set of health care quality measures for children in Medicaid and CHIP that by applying a standardized set of measures designed to measure and improve the quality of care. 

The 2017 Child Core Set includes 27 measures among the following domains of care: 1) Primary Care Access and Preventive Care; 2) Maternal and Perinatal Health; 3) Care of Acute and Chronic Conditions; 4) Behavioral Health Care; and 5) Dental and Oral Health Services. 

CMS released this year’s “Chart Pack” last week, which includes an analysis of state performance on 19 of the reported measures.  Arizona reported data from 11 of the indicators.  I Haven’t had the time to dive into the details, but if you’re interested in learning more you can explore the performance measures and the results in the September Report

US DHS Proposed Regulations Chill Programs that Address Social Determinants

Last Saturday the US Department of Homeland Security Secretary Kirstjen Nielsen proposed new rules that (when adopted) will consider a much wider range of public benefits when they evaluate applications for an immigration change of status or extension of stay request.  

DHS already uses information about whether applicants for legal permanent residency receive Temporary Assistance for Needy Families and Supplemental Security Income (SSI) when they evaluate applications.  After these new rules are adopted, they’ll also consider whether applicants receive Medicaid (AHCCCS), Medicare Part D Low Income Subsidy, the Supplemental Nutrition Assistance Program (food stamps), and Section 8 Housing program.  Once adopted, applicants that receive any of these benefits will be far less likely to be approved for a status change or stay extension.  I didn’t see any exemptions for children- so presumably benefits used by any noncitizen family member including kids would count.

Here are some take-aways from the draft: 

  • This is an issue of legal immigration- unauthorized migrants are largely ineligible for public assistance;

  • The use of public benefits by citizen children would not be considered a public charge;

  • This does not directly impact green card holders (the public charge test is not applied to green card holders applying for citizenship);

  • The proposed rule is not retroactive – meaning the public benefits received before the rule is final will not be counted as a public charge; and 

  • The proposed rules would not apply to refugees because existing statute prevents DHS from using the criteria for refugees.

A few months ago, DHS issued a discussion draft of the rule change that would have also included programs like Women Infant and Children (WIC) program, school lunch programs, subsidized marketplace health insurance and even participation in the Vaccines for Children program.

Even though the new draft doesn’t include vaccinations (VFC), WIC and marketplace insurance- many families will believe that the regulations do include these benefits and will elect not to use these important safety net benefits- as doing so will risk their immigration status.  As a result, families will have a more difficult time improving the health status of their families.  

The proposed new rules are 447 pages long- but a key place to look are pages 94-100 (that’s where the outline the new list of benefits that they intend to include).  The official proposal will be published in the Federal Register in a few weeks.  Once it’s officially published, the public will be able to comment on the proposed rule for 60 days.  The official version in the Federal Register will contain information about how to submit comments. I’ll keep my eye out for that.

History of Considering Public Benefits

The term “public charge” as it relates to admitting immigrants has a long history in immigration law, appearing at least as far back as the Immigration Act of 1882.  In the 1800s and early 1900s “public charge: was the most common ground for refusing admission at U.S. 

In 1999, the INS (DHS didn’t exist yet) issued Rules to "address the public’s concerns about immigrant fears of accepting public benefits for which they remained eligible, specifically medical care, children's immunizations, basic nutrition and treatment of medical conditions that may jeopardize public health.” Here's that final Rule from 1999, which didn't include Medicaid our housing benefits in the public charge definition.

Kids Care Included in the AHCCCS Budget Request

Good news.  AHCCCS’ 2020 budget request includes a general fund request of $7.9 million for KidsCare. The request was made under the assumption that the KidsCare trigger law will be amended this coming legislative session, preventing a freeze to CHIP enrollment.

There’s a trigger in state law that automatically freezes the Arizona KidsCare program if FMAP (the federal contribution) drops below 100%.  Under current federal law, the match rate is scheduled to go down to about 90% (9 federal dollars for every state dollar) on October 1, 2019.  So, if the current law isn’t changed during this next legislative session then we’ll likely have an enrollment freeze of the Kids Care program again this time next year.

The fact that AHCCCS included the $7.9M in state matching funds in the budget is encouraging, but the budget request isn’t enough to solve the problem- the legislature would need to change the statute and appropriate the funds to prevent an enrollment freeze.

Kids Care is run by AHCCCS and currently covers about 30,500 kids with a pretty good set of benefits and reasonable premiums.  It’s only available for kids in families that don’t qualify for regular Medicaid and who live in a family that makes under 200% of poverty.

Kids Care & ACA Advocacy

Election season is upon us and KidsCare and healthcare generally are key issues we want candidates for state office to weigh in on.  The Children’s Action Alliance has a helpful election’s page up and running now!  On it you can link to it to point the communities your organization serves to where they can contact candidates, see where candidates stand on issues, and register to vote. CAA is also launching a digital ads campaign around the key questions for candidates today.

Here’s is a fact sheet from Families USA explaining what’s at stake for people with pre-existing conditions in Arizona. The issue is a bit complicated to understand, but here goes for anyone that’s interested. Currently, there is a lawsuit, Texas v Azar, making its way through the courts that challenges the ACA as unconstitutional. 

Arizona Attorney General Mark Brnovich has signed Arizona on as a plaintiff state. If the lawsuit is successful, the protections for people with pre-existing conditions, along with other parts of the ACA, will be repealed.  

We don’t know the timetable on a final court decision, but we do know that, if the lawsuit is successful, Arizona’s law is set up so that these protections will essentially be repealed simultaneously in state statute.

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.

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.

Leveraging Doulas to Improve Birth Outcomes

Doulas are professionals who provides physical, emotional, and informational support to a woman throughout pregnancy, childbirth, and postpartum. Doula’s act as a facilitator between the laboring women and her physician by ensuring that mom and dad get the information they need in a way that they understand so they can make informed decisions. 

A growing body of evidence suggests that continuous support from doulas or other non-clinical labor support can improve birth outcomes for both mothers and infants, fewer preterm and low-birth weight infants, and reductions in cesarean sections. In fact, when doula services are included throughout the pregnancy and birth process, births cost less. A recent study found that when a doula is included in the process births cost an average of $986 less - including the doula service fee.

Currently, Minnesota and Oregon take advantage of the fact that doulas can reduce healthcare costs while improving outcomes in their state Medicaid programs. In the 2018 budget, Minnesota increased the reimbursement rates for doulas.  The new law also requires Oregon’s coordinated care organizations (which deliver Medicaid services) to provide information about how to access doula services online and through any printed explanations of benefits. The law tasked Oregon Medicaid with facilitating direct payments to doulas, which was addressed through rulemaking.  

Several organizations, such as DONA International, provide doula training and certification. Women can also choose to become certified as community-based doulas through HealthConnect One. This community-based doula program model, which has been replicated nationwide to serve unique populations, trains doulas to provide culturally sensitive pregnancy and childbirth education to underserved women in their own community. While all doula services can be beneficial, creating a standard for the training and certification of doulas may improve understanding and acceptance of doula care.

Looking for more info? Access this UA Issue Brief on Doula Coverage to Help Minimize Arizona’s Birth Woes

Who's a Doula?

By AzPHA Member Prashanthinie (Prashi) Mohan, MBA

Over the last few years, there has been more and more focus on the triple aim – improving patient experience, reducing costs, and improving population health. Accomplishing these goals requires the system to be creative and actively look for new approaches to lowering costs while improving outcomes.

Doulas are increasingly being recognized as a professional that can do just that. 

Several studies have shown that moms who have doula services during their pregnancy and delivery have fewer cesarean sections and epidurals, reduced premature births, higher rates and a longer duration of breastfeeding. In March 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal medicine issued a consensus statement which explicitly stated that published data has indicated better labor and delivery outcomes when continuous support personnel such as doulas are used.

So, we’ve got better outcomes covered, what about lower costs?

Recent evidence on the return on investment for doulas is encouraging. In addition to improving birth outcomes, doula coverage can also be cost effective (if not cost saving) to Medicaid programs. Doula coverage can help reduce costs by lowering the rate of pre-term and cesarean deliveries. One study conducted across 10 states computed an average savings of $986 per doula supported birth.

Despite the evidence on doula-supported births, only 6% of U.S. women who give birth are estimated to have doula support. Low income women and women of color, who are the most likely groups to want doula services, may not be able to afford doula services, which can cost $500 to $750 per birth in Arizona.  Because few health plans currently reimburse for doula services, most women are unable to take advantage of the improved outcomes and enhanced birth experience that doulas provide.

Licensed and culturally trained doulas who are from the minority communities can not only provide emotional support during the prenatal period and the delivery process, but can also help facilitate key communication between the mother and her care providers.

The question is, what are we waiting for? Doulas have proven to be effective in improving birth outcomes cost effectively in other states in the U.S. It’s time Arizonans start looking into how doula services can be efficiently reimbursed for the mothers in our state.

CMS Position on Native American Exemptions from State Medicaid Work Requirements Complicates AZ Waiver Request

A 2015 AZ law requires AHCCCS to annually ask the CMS for permission to require work (or work training) and income reporting for “able bodied adults” and a 5-year lifetime limit on AHCCCS eligibility.  The work requirement waiver requests turned in during the Obama Administration were denied, but the new administrator CMS has publicly said (and written) that they're receptive to proposals from states to require work or community engagement for people who want to receive Medicaid.

Late last year AHCCCS submitted their annual official waiver request asking permission to implement the following requirements for certain adults receiving Medicaid services including a requirement to become employed, actively seek employment, attend school, or partake in Employment Support and Development activities (with exceptions) and a requirement to bi-annually verify compliance with the requirements and any changes in family income.  CMS has not yet ruled on the AZ request.

One of the exempted groups in the waiver request is American Indians.  Starting Friday (when HB 2228 takes effect) the exemption of tribal members won’t just be an administrative decision, but one required by Arizona law.  That’s because HB 2228 requires AHCCCS to exempt tribal members from their work requirement waiver requests.  Here’s the exact statutory language:

36-2903.09.  Waivers; annual submittal; definitions

B.  SUBSECTION A OF THIS SECTION DOES NOT INCLUDE OR APPLY TO AMERICAN INDIANS OR ALASKA NATIVES WHO ARE ELIGIBLE FOR SERVICES UNDER THIS ARTICLE, THROUGH THE INDIAN HEALTH SERVICE OR THROUGH A TRIBAL OR URBAN INDIAN HEALTH PROGRAM PURSUANT TO THE INDIAN SELF-DETERMINATION AND EDUCATION ASSISTANCE ACT AND THE INDIAN HEALTH CARE IMPROVEMENT ACT.

However, a letter signed by CMS official Brian Neale suggests that CMS won’t be approving waiver requests that exempt tribal members.  In a letter to tribal members he writes, regarding exempting tribal members from state Medicaid eligibility work requirements “… Unfortunately, we are constrained by statute and are concerned that requiring states to exempt AI/ANs from work and community engagement requirements could raise civil rights issues.”

In a nutshell, (beginning Friday) Arizona law will require AHCCCS to exempt American Indians from their directed work requirement waiver request (they have already administratively elected to do so).  CMS is on record saying that they're constrained by statute and have civil rights concerns about allowing states to exempt American Indians from work requirement and reporting waivers. 

It stands to follow that CMS may very well deny Arizona’s request to exempt tribal members from work and reporting requirements despite our new law (36-2903.09 (B)). If that happens, there will surely be a legal review to determine exactly the intent of 36-2903.09 (B)

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. 

Immigration Status, Public Benefits, Health & Access to Care: A Primer

With all the attention on immigration status and its intersection with public benefits and access to health care- I thought I’d take a crack at summarizing these issues for our membership.  Here goes:

Noncitizens make up about 7%  percent of the US population. It’s not surprising that they’re more likely to be low-income and uninsured than citizens- in part because of the opportunity limitations. In fact, 71% of undocumented adult noncitizens are uninsured.  By and large, many of them rely on Federally Qualified Health Centers for their primary care and other healthcare- in part because FQHCs have sliding fee scale service fees and serve immigrants regardless of their immigration status.

Medicaid generally limits eligibility for immigrants to qualified immigrants with refugee status or veterans and people lawfully present in the US for 5 years or more.  State Medicaid programs can elect to provide coverage to legally present immigrants before the 5-year waiting period ends (Arizona does not).

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (often referred to as PRWORA or welfare reform) is the federal law that created Medicaid’s “qualified immigrant” standard.

Other federal safety net programs like Temporary Assistance for Needy Families and the Supplemental Nutrition Assistance Program (food stamps) also apply the five-year waiting period for legally present immigrants.

States can get matching funds from Medicaid (CMS) when they choose to provide Medicaid coverage to legally present immigrants who are children or pregnant women before the end of the 5-year waiting period.  33 states have elected to cover lawfully residing immigrant children, and 25 states cover legally present pregnant women (Arizona does not).

The Affordable Care Act made it possible for the legally present immigrants who are ineligible for Medicaid due to being in the five-year waiting period to qualify for commercial coverage and subsidies on the Federal health insurance marketplace.

Immigrants eligible for Medicaid or employer-sponsored insurance face several coverage and service barriers.  As I mentioned in a blog a few weeks ago immigration officials consider the likelihood of individuals and families becoming a “public charge,” which can result in denied admission to the US or status as a lawful permanent resident.

Fear that using safety net services will mean that they’ll be considered a public charge contributes to some families of mixed immigration status avoiding use of services like TANF, Medicaid, SNAP etc.  Some eligible immigrants avoid services because they think family members will become involved in immigration enforcement actions.

Research findings by the Kaiser Family Foundation found that changes in healthcare use and decreased participation in Medicaid and the Children’s Health Insurance Program because of this immigration policy.

Anyway, it’s a complicated system but I hope this makes it a little clearer.

Community Paramedicine Continues to Mature in AZ

Community paramedicine has been a paradigm shift for the use of paramedics in the US- and Arizona has been a national leader.  It’s a new model in which paramedics function outside their usual emergency response & transport roles- delving into the world of primary care.  As the health care world increasingly shifts toward prevention and well care- the system will increasingly demand more folks that can function in a community health (primary care and prevention) role.  Community paramedicine is increasingly being recognized as a promising solution to efficiently increase access to care (especially for underserved populations). 

For example- paramedics could shift from a sole focus on emergency response to things like: 1) providing follow-up care for folks recently discharged from the hospital to prevent unnecessary readmissions; 2) providing community-based support for people with diabetes, asthma, congestive heart failure, or multiple chronic conditions; and/or 3) partnering with community health workers and primary care providers in underserved areas to provide preventive care. 

One component of Community Paramedicine is known as “Treat and Refer” and it has really taken a step forward in the last couple of years in Arizona.  A couple of years ago the initiative was launched under the leadership of AzPHA Members David Harden, Terry Mullins, Dr. Ben Bobrow and others at the ADHS.

It’s called the Arizona Treat and Refer Recognition Program and was developed in partnership with the ADHS Bureau of EMS & Trauma Systems, AHCCCS, and the EMS community. Organizations that earn Treat and Refer recognition implement the program under the direction of their medical director and chief executive.  Once recognized, the EMS Agency can seek reimbursement from AHCCCS for the services they provide.  You can check out the AHCCCS website to learn more about provider registration.

Five EMS agencies have now been recognized as Treat & Refer EMS agencies. The T&R Program establishes a means for recognized EMS agencies demonstrating optimal patient safety and quality of care by matching treatment, transport, and care destination options to the needs of the 9-1-1 patient; and provide recognized EMS agencies the opportunity to seek reimbursement from AHCCCS.


The ADHS Bureau of EMS & Trauma Systems offers a pre-application technical review service to EMS agencies considering applying for recognition. The service includes a comprehensive review of EMS agencies’ education modules, standing orders, patient follow-up process, and performance improvement/quality assurance process.

Policy Update: Family Planning, ACA Lawsuit, Work Requirements and Assault Weapons

Summer & Fall Public Health Activities in AZ

Interested in finding out about the various public health conferences, meetings and events this Summer and Fall?  

Bookmark our AzPHA Upcoming Events webpage.  It’s as simple as that.  If I’ve missed something- let me know at willhumble@azpha.org!

 

Proposed Title X Funding Changes Likely to be a PH Burden

The US Department of Health and Human Services has proposed changes to the rules for the federal family planning services program, known as Title X.  If the new rules are adopted as proposed, it’ll require Title X family planning services to be physically and financially separate from abortion services.

Many family planning clinics offer both family planning and abortion referral services, and if the changes are ultimately implemented many of the programs would likely decide not to take Title X funding, which would have a big impact on the network of available services and they’d have fewer resources available for STD screening, treatment and outreach.

BTW: Title X funds have never been allowed to be used for abortions. The proposed rule is available for public comment until the end of July.  You can read more about the proposed rule and comment by visiting the Federal Rulemaking Portal: http://www.regulations.gov. Just follow the instructions to submit.  Your comments might not influence the outcome, but at least you’ll have done your part. That and voting this Fall.

 

Federal Government Won’t Defend the Affordable Care Act in Court

So far, the Affordable Care Act has survived the 2 court challenges that made it to the US Supreme Court.  Back in 2012 the ACA was upheld by the Supreme Court for the first time (by a 5-4 margin) in the National Federation of Independent Business v. Sebelius case.   It was upheld again in 2015 when (in a 6-3 decision) the Supreme Court upheld ACA’s federal tax credits for eligible Americans living in all 50 states (not just the 34 states with federal marketplaces).

But, there are additional challenges out there that haven’t made it to the Supreme Court yet. One that’s progressing through the courts is a challenge filed by 20 states (including Arizona) arguing that the ACA’s individual mandate is unconstitutional and key parts of the act — including the provisions protecting those with pre-existing conditions — are invalid. 

This week Attorney General Jeff Sessions acknowledged that while "the Executive Branch has a longstanding tradition of defending the constitutionality of duly enacted statutes if reasonable arguments can be made in their defense," the Attorney General will not defend the ACA from this challenge.  

The implications could be profound.  The ACA could potentially be completely overturned- or portions that require health plans to cover pre-existing conditions could be eliminated along with the mandate that persons have health insurance.

 

Medicaid Work/Community Engagement & Reporting Requirements

Any day now, the Centers for Medicare and Medicaid Services (CMS) will be approving Arizona’s request to include work requirements and/or community engagement and reporting requirements as a condition of Medicaid enrollment.  The request filed by AHCCCS is required by Senate Bill 1092 (from 2015) which requires them to ask CMS’ permission to implement new eligibility requirements for “able-bodied adults”.

AHCCCS initially proposed implementing the following requirements for able-bodied adults receiving Medicaid services including: 1) a requirement for all able-bodied adults to become employed or actively seeking employment or attend school or a job training program; 2) requiring able-bodied adults to verify monthly compliance with the work requirements and any changes in family income; 3) banning an eligible person from enrollment for one year if the eligible person knowingly failed to report a change in family income or made a false statement regarding compliance with the work requirements; and 4) limiting lifetime coverage for all able-bodied adults to five years except for certain circumstances.

Hundreds of comments were submitted (including comments from AzPHA) urging the agency to consider modifications to the initial waiver request.  AHCCCS later issued a final waiver request which includes exemptions for:

  • Those who are at least 55 years old;
  • American Indians;
  • Women up to the end of the month in which the 90th day of post-pregnancy occurs;
  • Former Arizona foster youths up to age 26;
  • People determined to have a serious mental illness (SMI);
  • People receiving temporary or permanent long-term disability benefits from a private insurer or from the government;
  • People determined to be medically frail;
  • Full-time high school students older than 18 years old;
  • Full-time college or graduate students;
  • Victims of domestic violence;
  • Individuals who are homeless;
  • People recently been directly impacted by a catastrophic event such as a natural disaster or the death of a family member living in the same household;
  • Parents, caretaker relatives, and foster parents; or
  • Caregivers of a family member who is enrolled in the Arizona Long Term Care System

A subsequent letter from the AHCCCS Administrator suggested that they (AHCCCS) are suspending their request for a 5-year limitation on lifetime benefits (for some members) for now.  Here’s our letter from back in February of 2017. 

 

Kaiser Family Foundation Issue Brief on Work Medicaid Requirements

Last month the Kaiser Family Foundation published an Issue Brief regarding CMS’ recent decisions to grant states the ability to experiment with their Medicaid programs that condition Medicaid eligibility on work or community engagement. The Issue Brief examines evidence of the effects of the Medicaid expansion and some changes being implemented through waivers.

Many of the findings on the effects of expansion are drawn from the 202 studies included in our comprehensive literature review that includes additional citations on coverage, access, and economic effects of the Medicaid expansion.

Regarding work requirements, the Brief concludes that “state-specific studies in Colorado, Kentucky, Michigan, Pennsylvania and most recently Montana and Louisiana have documented or predicted significant job growth resulting from expansion. No studies have found negative effects of expansion on employment or employee behavior. In an analysis of Medicaid expansion in Ohio, most expansion enrollees who were unemployed but looking for work reported that Medicaid enrollment made it easier to seek employment, and over half of expansion enrollees who were employed reported that Medicaid enrollment made it easier to continue working.  Another study found an association between Medicaid expansion and increased volunteer work in expansion states.

Furthermore, “work requirements have implications for all populations covered under these demonstrations. Those who are already working will need to successfully document and verify their compliance and those who qualify for an exemption also must successfully document and verify their exempt status, as often as monthly. States would incur costs to pay for the staff and systems to track work verification and exemptions.”

If you’re interested in the public health policy implications of our upcoming work/community engagement and reporting requirements, the KFF Issue Brief is a must-read.

 

Court Challenge to Kentucky’s Work Requirements being Heard this Week

Oral arguments are being heard this week in DC challenging Kentucky’s requirements that members work or participate in "community engagement" activities such as job training, school or volunteering. The case was filed in January by the National Health Law Program, the Kentucky Equal Justice Center and the Southern Poverty Law Center.  The outcome could have implications for AZ’s upcoming requirements.

Read National Health Law Program's guide on what to expect from oral argument.

American Medical Association Endorses Assault Weapon Ban

The American Medical Association – Nation’s largest physician group – endorsed a ban on assault weapons as part of a package of measures aimed at combating the epidemic of gun violence in the US. The member driven initiative was endorsed at their annual policy conference. They also endorsed a ban on bump stocks, which basically turn semi-automatic rifles into automatic weapons. 

In a statement AMA Immediate Past President David O. Barbe, MD, MHA said: “People are dying of gun violence in our homes, churches, schools, on street corners and at public gatherings, and it’s important that lawmakers, policy leaders and advocates on all sides seek common ground to address this public health crisis, in emergency rooms across the country, the carnage of gun violence has become a too routine experience.”

 

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/

AzPHA Comments on AHCCCS' Proposed Network Sufficiency and Appointment Standards

May 11, 2018

 

Thomas J. Betlach

Administrator,

Arizona Health Care Cost Containment System

801 E Jefferson Street

Phoenix, AZ 85034

 

Dear Administrator Betlach:

I write on behalf of the Arizona Public Health Association (AzPHA) – one of Arizona’s oldest and largest membership organizations dedicated to improving the health of Arizona citizens and communities. An affiliate of the American Public Health Association, our members include health care professionals, state and county health employees, health educators, community advocates, doctors, nurses and students.

Thank you for the opportunity to comment on your AHCCCS Contractors Operations Manuals for the upcoming October 1 Integrated Care Contracts.  We have reviewed the proposed 400 Series Manuals and have comments on ACOM 436 (Minimum Network Requirements) and 417 (Appointment Availability, Monitoring and Reporting).

ACOM 436 Minimum Network Requirements

We applaud the Administration for applying measurable and verifiable standards for geographic network adequacy.  We like the way the Administration is using a standard which includes a percentage of the members within both a discrete distance and time from a provider in the various categories. The percentages and distances for rural and urban areas seem reasonable.  We encourage you to keep these types of easily measurable and verifiable standards in the final ACOM 436.

County public health departments support medical homes especially in under-served areas.  Their core services include vaccinations, sexual transmitted disease testing and treatment, reproductive health, and tuberculosis prevention and control.  These are services that patients are not always able or willing to access in their medical home. When county health departments are not a network provider, this critical health care infrastructure component is unavailable to members which can gave a substantial negative impact on community and member health. Please require your new integrated managed care plans to include Public Health departments in their health care provider networks. 

This will ensure fairness in providing services to your members, provide revenue that enables county health departments to continue to serve their communities, and prevent taxpayers from paying twice for access to critical health services.

A key to making member choice meaningful requires contractors to be transparent about whether they are meeting Minimum Network Requirements.  When contractors are out of compliance with the ACOM 436 Standard(s), we encourage the Administration to require contractors to disclose on their websites, newsletters and other member communication materials which standards they have not complied with and/or have requested exceptions from so that Members can take that information into consideration as they choose plans. This disclosure standard may need included in ACOM 404 for compliance purposes. The information should also be added to the AHCCCS enrollment websites

ACOM 417 Appointment Availability, Monitoring, and Reporting

We applaud the Administration for applying statistical methods and measurable and verifiable standards for regulating appointment availability, monitoring and reporting. We like the way the Administration is using a standard which includes an explanation of how sample sizes meet a 95% statistically significant confidence level including the calculations used to confirm the confidence level.  We encourage the Administration to keep these criteria and the reporting template.

As with ACOM 436, we encourage the Administration to require contractors to disclose on their websites, newsletters, and other member materials which standards they have not complied with and/or have requested exceptions from so that Members can take that information into consideration as they choose plans. This disclosure standard may need included in ACOM 404 for compliance purposes. The information should also be added to the AHCCCS enrollment websites.

Sincerely,

 

Will Humble, MPH

Executive Director,

Arizona Public Health Association

Arizona's 2018 Legislative Session in the Books

Well, Arizona’s legislative session ended last week, so you’re spared my impossibly long policy updates.  You can visit this PowerPoint to dive into the good things, bad things, and the missed opportunities this year.  It’s still a draft summary of the Session because the Governor hasn’t taken action on several bills (voluntary certification of community health workers, public health measures in schools, dental therapy, food truck licensing, and fresh produce in SNAP). BTW- Let me know if you see anything I've left out of the draft powerpoint so I can update it before my Webinar next week

I’ll be doing a Webinar about the legislative session on Thursday May 17 at noon in conjunction with the UA Center for Rural Health & the UA Telemedicine Program.  Visit the AZ Telemedicine Program’s Website to register.

 

FDA Finally Implementing ACA’s Menu Labeling Requirement

You might have noticed that more and more restaurants and fast food places are starting to put calorie and other nutrition information on their menus.  That’s not a coincidence or accident- they’re implementing the menu nutrition labeling requirements in the Affordable Care Act.  Section 4205 of the ACA requires restaurants with 20 or more locations to post calorie content information for standard menu items directly on the menu and menu boards.  Vending machine operators with 20 or more machines are also required to disclose calorie content for certain items. 

Nutrition clarity is a real opportunity for public health change.  Not only will the new labels give the public key information to help them make better decisions about what they buy for themselves and their families- it’ll give pause to restaurants before they label their menus- giving them an opportunity to change ingredients to lower calorie counts.  It may even spur a trend away from super-sizes and toward more appropriate and reasonable serving sizes.  With 32% of the calories consumed in the US tied to eating outside the home- this is an important opportunity. 

Anyway, the FDA announced this week that they’re finally implementing the requirements that were established by the ACA.  Another evidence-based policy intervention brought to you by the Affordable Care Act.

 

CMS Denies Kansas’ Request for 3-year Lifetime Medicaid Eligibility

This week the Centers for Medicare and Medicaid Services Administrator denied Kansas’ request to impose a 3-year lifetime limits on Medicaid eligibility. 

Her decision bodes well for us in Arizona- at least when it comes to lifetime coverage limits (although CMS is poised to almost certainly approve AZ’s work/work training request).  Arizona law requires AHCCCS to annually ask CMS for permission to require work (or work training) and income reporting for “able bodied adults” and a 5-year lifetime limit on AHCCCS eligibility (with some exceptions).

A few months ago AHCCCS turned in their official waiver request asking permission to implement those requirements.  The AHCCCS Director recently postponed the negotiation process of the lifetime limit request to expedite approval of the work requirements.  See his letter here.  Word on the street is that AHCCCS expects approval of the work requirements in June.

 

Mid-year Federal Budget Cut Request

This week the White House submitted a special message to Congress requesting they rescind $15B bill in budget authority from the current fiscal year. The proposal includes unobligated balances from prior-year appropriations and reductions to budget authority for mandatory programs.

Below are selected programs proposed for rescission by the Administration that may impact public health programs. For more information, view the entire rescission proposal here.

  • Children’s Health Insurance Fund: The proposal would rescind $5B in amounts made available by the Medicare Access and CHIP Reauthorization Act of 2015 to supplement the 2017 national allotments to states, including $3B in unobligated balances available on October 1, 2017. 

  • Child Enrollment Contingency Fund: The proposal would rescind $2B in amounts available for the CHIP Contingency Fund, of which there were $2.4B available. The Contingency Fund provides payments to states that experience funding shortfalls due to higher than expected enrollment. 

  • Centers for Medicare and Medicaid Innovation (Innovation Center): The proposal would rescind $800M in amounts made available for FY11-19 for the Innovation Center, of which there were $3.5B available on October 2017. The Innovation Center was created to test innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid, and CHIP while preserving or enhancing quality care.

 

Speak for Health: Fund Public Health in 2019

As Congress begins its work on the FY 2019 appropriations process, Speak for Health and tell our members of Congress  to reject the proposed cuts to important public health programs in the president's budget proposal and instead to prioritize public health by building upon the important increased investments in public health provided by Congress in FY 2018.

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Most of you know Dr. Bob England, who's been on the AZ public health scene for the last 30 years including 12 years as the Director of the Maricopa County Public Health Department.  You know that he's a terrific cartoonist.  But did you know he's an engaging travel writer?

Bob's been living for the last couple of months just outside of London.  He's been writing some terrifically 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.  Here’s Travelogue 3: Nutrition. Enjoy.

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If you haven’t yet become a member of AzPHA please consider joining our team!

Here’s information about our Individual & Organizational Memberships