New USPSTF Recommendations for HIV Will Have a Powerful Public Health Impact

Ever since the passage of the Affordable Care Act, a prevention model of health has been increasingly weaving its way into the fabric of traditional models of care.  That’s because the ACA expanded the role of preventive services in the US health care delivery system via various incentives. 

For example, the “Category A & B” preventive services that are recommended by the United States Preventive Services Task Force (USPSTF) are now included (at no cost to consumers) in all Qualified Health Plans. In addition, many employer-based and state Medicaid programs routinely cover Category A & B services once they’re recommended by the USPSTF. 

The USPSTF is an independent, volunteer panel of experts in prevention and evidence-based medicine. The Task Force works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications.

The Task Force analyzes priority preventive health services and assigns the a letter grade (an A, B, C, or D grade or an “I Statement”) based on the strength of the evidence and the balance of benefits and harms of the preventive service.

Currently, the USPSTF recommends 51 Category A & B Preventive Health Services – which include things like screening tests, counseling, immunizations, and preventive medications for adults, adolescents, and children. 

The preventive services that have an A or B grade are presented in alphabetical order and by the date they were recommended on the Task Force website.

This month they added 2 new recommendations related to HIV: 

You can browse the USPHS website and check out the preventive services that they have evaluated but got a lower grade. Most of the services are broken down by age, gender and other risk factors.

Should Pharmacists Prescribe PrEP as Part of the Solution for HIV Prevention

As I mentioned above, the U.S. Preventive Services Task Force this week put out their final recommendation statement on preexposure prophylaxis (PrEP) for the prevention of HIV infection. The Task Force found that clinicians should offer PrEP to persons at high risk for HIV.
The task force found convincing evidence that PrEP is of substantial benefit in decreasing the risk of HIV infection in persons at high risk of HIV acquisition.  They conclude that PrEP is associated with small harms, including kidney and gastrointestinal adverse effects and that (with high certainty) the benefit of PrEP (with oral tenofovir disoproxil fumarate–based therapy) is substantial. They classified it as a Category A intervention.

The final recommendation statement can also be found in the June 11 issue of JAMA. The impact of the Category A recommendation is important because PrEP will now be included (at no cost to consumers) in Qualified Health Plans offered on the Marketplace.  In addition, many employer-based and state Medicaid programs routinely cover Category A & B services once they’re recommended by the USPSTF. 

This week there was an article in the American Journal of Public Health that makes an argument that pharmacists should have a role in HIV prevention related to preexposure prophylaxis (PrEP), postexposure prophylaxis (PEP), and HIV testing and harm reduction.

The authors make a compelling case that, because PrEP and PEP require a prescription, control of the epidemic face hurdles like limited network capacity, physician shortages, and other access to care barriers. They argue that pharmacists are an untapped resource that are more easily accessible and available without appointment. Also, because pharmacies and pharmacists aren’t linked to specific health conditions, the setting is considered largely free of HIV-related stigma.

Of course, expanding into this role would require pharmacists to work within each jurisdiction’s scope of practice laws and policies, ensure HIV literacy through pharmacist training programs and continuing education courses and building infrastructures for billing and reimbursement, and health information technology.

Interesting idea for sure.

What’s with the New EPA Coal Burning Plant Rule?

There’s a good chance you heard that the EPA changed their coal power plant environmental regulations this week. Here’s a quick summary of what those changes are.

The story starts in 2013 when the EPA (under the Obama Administration) issued regulations that applied to new coal fired electricity generation plants.  The rules were called “New Source Performance Standard” or “NSPS.”

The NSPS required that any new generation units fueled by natural gas meet a limit of 1,000 pounds of CO2 per megawatt-hour and allowing new coal plants to emit 1,100 pounds of CO2 emissions per megawatt-hour of electricity generated.  The coal industry didn’t like the rule because the most advanced coal-fired power plants emit 1,700 pounds per megawatt-hour.
The EPA then issued a 2nd rulemaking in 2015 with the “Existing Source Performance Standard” or “ESPS” Rules.  The ESPS rule aimed to reduce overall emissions of CO2 from the nation’s power sector by 32% from 2012 to 2030. Under the 2015 rules, existing coal plants would have had to comply with a 1,300 pounds of carbon per megawatt hour standard (this irritated the industry because the best plants can only achieve 1,700 lbs per megawatt hour).

The U.S. Chamber Litigation Center filed a lawsuit challenging the EPA’s 2015 rules and the US Supreme Court issued a stay on the rules which halted implementation of those 2015 ESPS rules. 

This week the EPA repealed and replaced the ESPS rules (for existing plants) with what they call the Affordable Clean Energy (ACE) rule- which essentially gives states three years to create their own plans to cut emissions at existing plants mainly by encouraging coal-fired power plants to improve their efficiency. The old carbon standards were eliminated. 

The new rules set some guidelines for states to develop performance standards for power plants that boost the amount of power produced per ton of carbon. The original draft proposal would have allowed new coal plants to skip the federal permitting process and use the new “ACE” process, but that was dropped from the final ACE rule.

Arizona has 5 coal burning plants: the Apache Generating Station (Cochise County), the Cholla Power Plant (Navajo County), the Coronado Generating Station (Apache County), the Navajo Generating Station (Apache County & closing later this year), and the Springerville Generating Station in Apache County.  Under the new rules issued this week, these facilities will now be subject to state regulation via the new ACE standards- presumably by ADEQ.

Over the long run, the percentage of energy generation that comes from coal in the US will continue to decline because coal power generation  is simply more expensive than natural gas and solar and wind sources.

To look at the cost of generation for the various approaches you can visit this US Energy Information Administration Document which compares the capital, operational and transmission costs for various forms of energy generation-  and you’ll see that coal is way more expensive than natural gas, wind, and solar technologies. 

Arizona Policies, Resources and Recent Investments are Addressing Rural Healthcare Workforce Shortages

Healthcare workforce shortages often contribute to health disparities in rural AZ.  That’s because rural communities tend to have fewer physicians, nurses, specialists, and other healthcare workers…  and at the same time face higher rates of chronic disease, mental illness, and obesity than urban areas. Having enough healthcare personnel in shortage areas can contribute to those health disparities. 

Additionally, health care providers working in shortage areas can experience isolation from their peers and burnout from seeing a greater number of patients and working longer hours than those in non-shortage areas.

A critical element to ensuring an adequate healthcare workforce is to improve the reach of provider recruitment programs, which can build a strong and diverse healthcare workforce that represents the population served. 

This year was particularly successful at the Legislature as they approved an additional $750K for the state loan repayment program (bringing the total budget to $2.75M) as well as more resources for rural Graduate Medical Education ($1.6M for rural Graduate Medical Education -$5.5M w the federal match)  – which can be use to bolster graduate training in rural AZ (this GME training is really important because it’s a key factor in where a provider practices over the course of her or his career- improving rural networks). There was also an additional $750K that was invested in the North Country GME program.

Arizona Primary Care Office

Arizona is fortunate to have an effective Primary Care Office program at the ADHS’ Bureau of Women and Children’s Health along with public policies that have been passed in the state legislature that help to improve the state program’s effectiveness. 

Our in-AZ resources to improve workforce capacity and access to care in rural and underserved AZ include the Arizona State Loan Repayment Programs, J-1 Visa Waiver Program, and at the national level, the National Health Service Corps and Nurse Corps.

Our state Primary Care Office also manages data collection regarding healthcare provider shortage areas (HPSAs) and information like Primary Care Area Statistical Profiles as well as maps and a host of additional data resources.

UA Center for Rural Health

We also have terrific programs at the UA Center for Rural Health which has rural health programs like the Rural Hospital Flexibility Program (AzFlex), the Small Rural Hospital Improvement Program (AzSHIP), Arizona First Responders Initiative (FR-CARA), The Rural Health Professions Program (RHPP), Workforce Data & Analysis (CRHWorks), Arizona Rural Recruitment and Retention Network (Az3RNet), Students Helping Arizona Register Everyone (SHARE), the Prescription Drug Overdose Program, and Health Insurance Assistance.

Arizona Area Health Education Centers

Arizona also has a unique system of AZ Area Health Education Centers that are established under state law (voter approved) “… enhance access to quality healthcare, particularly primary and preventive care, by improving the supply and distribution of healthcare professionals through educational partnerships between academic and community organizations in rural and urban medical underserved areas.” 

The Program has a state office at the UA and several local AHECs that promote community and educational partnerships to enhance access to quality health care with an emphasis on the needs of rural and urban underserved communities and populations. Their missions also include educational programs in partnership with academic institutions, communities, health care agencies, and other organizations that promote the health of Arizona residents.

Arizona Rural Health Association

We’re also fortunate to have the Arizona Rural Health Association (AzRHA) in our state doing advocacy for rural health.  The AzRHA was established in 1994 as an independent organization after serving as the Advisory Committee of the University of Arizona Rural Health Office (RHO) for many years. While AzRHA continues to serve as the RHO advisory body, its functions have been expanded to cover many areas involving advocacy for rural healthcare programs.

Access to healthcare is an essential component of health and wellness. By providing financial incentives for clinicians to practice and train in rural areas and by collecting data on provider shortages and using that data to make policy adjustments, Arizona is increasingly poised to make measurable improvements in rural networks as a result of this year’s legislative session decisions.

U of A Study Examines Emergency Department Use During the Recession

AzPHA member Patrick Wightman from the UA Center for Population Science and Discovery recently published an Issue Brief examining the impact that the freeze on “childless adult” enrollment in AHCCCS during the Great Recession had on the use of hospital and emergency department services. 

Because Arizona conducted a natural experiment by freezing Medicaid enrollment among childless adult, and the fact that data are available to measure the effect of those policy changes, Patrick was able to compare people’s behavior with health insurance to their behavior without it.  The fact that the freeze lasted years allowed him to examine any impact of pent-up demand following the lifting of enrollment freeze.

Here’s a link to the entire Issue Brief , which includes the entire results including several useful graphs, but here’s the Summary from the Issue Brief.

“While the trends presented here are descriptive, they occur in the framework of two significant “natural experiments”, the first drastically restricting low-income individuals’ access to public health insurance, and the second once again expanding that access.  Because these policy changes happen at the state and federal levels, beyond the control of beneficiaries, it can be inferred that, in large part, they are the cause of the beneficiaries’ behavior, in this case their health care utilization.

In this context, the patterns shown here provide strong evidence that health care utilization, at least in the form of ED visits and hospitalizations, follows the availability of health care, in the form of health insurance.  While this finding is not unanticipated in the case of hospital visits, in the case of ED visits it is perhaps somewhat surprising, at least to the extent that ED visits represent “legitimate” medical emergencies.”

In the News

Opioid Use Disorder Treatment Medications

Earlier this week AHCCCS announced that they’ve accepted the recommendations of their Pharmacy and Therapeutics Committee and will be adding an additional buprenorphine medication (sublingual) to their preferred formulary list and a streamlined prior authorization process for a long acting injectable medication (effective 10/1). Here’s the story from the Republic and the Cap Times.

Hacienda Healthcare Enforcement Action

The ADHS issued a Notice of Intent to Revoke the license of a Hacienda Healthcare on Friday (here’s the story from the Republic). Apparently, a patient at the facility had larvae on a stoma, prompting the investigation. As you’ll recall, the facility previously had not been required to have a license – until SB1211 was passed and signed. The Governor signed the law with an emergency implementation clause (making it immediately effective) on 4/24/19.

A survey was conducted on 4/23 & 4/24 (that found no deficiencies) and the facility was apparently issued a license on 4/26. According to the news report staff from 3 state agencies (ADHS, AHCCCS, and ADES) are monitoring the facility and working on an investigation.

WHO Declines to Call Ebola Outbreak a Global Public Health Emergency

The now months-long Ebola outbreak in the Democratic Republic of the Congo (which spread to Uganda this week) is an emergency for the DRC and its neighbors, but according to the WHO this week, it doesn’t constitute a global health emergency.

The core of the decision was that the additional powers that come with an emergency declaration aren’t needed and, if used, may cause more harm than good.  One of those powers would allow the WHO to disclose information about a disease event to other countries without the consent of the outbreak country.  Emergency powers also give the WHO director-general authority to issue temporary recommendations regarding trade and travel.  However, the WHO’s recommendations on travel and trade have sometimes been ignored during other declarations.

On the other hand, declaring an emergency can be quite helpful in raising cash to fund public health and treatment interventions, and not declaring an emergency may miss opportunities to get additional resources to the outbreak areas.

More than 2,100 cases and 1,400 deaths have been reported in the DRC, making this the second largest Ebola outbreak on record.  It’s still 10% the size of the 2014-2016 West African outbreak, but has been difficult to control because of political and civil unrest in the DRC -despite the fact that there is now a vaccine that wasn’t available until the end of the 2016 outbreak.

Merck is making an additional 450,000 doses of the experimental Ebola vaccine for the DRC- but it takes a year from start to finish to make the vaccine. More than 130,000 DRC people have been vaccinated so far.