Will Humble Opioids, Wills Blog

AzPHA Letter to AHCCCS Urging them to Consider Adding Additional Opioid Use Disorder Medications

AzPHA sent the following letter to AHCCCS’ Pharmacy & Therapeutics Committee (which meets next Thursday), urging them to consider expanding the MAT Preferred Drug List for treating AHCCCS members with an opioid use disorder.  This work fits under the Administrative Advocacy portion of our mission.

I write on behalf of the Arizona Public Health Association – 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 the Pharmacy & Therapeutics Committee’s recommendation regarding the Preferred Drug List for Medication-Assisted Treatment (MAT) for opioid use disorder.

As Governor Ducey correctly declared, opioid addiction and abuse constitutes a public health emergency in Arizona.  While the Arizona Opioid Epidemic Act passed last year included several evidence-based interventions that will have an impact on the public health crisis over time, we believe that additional measures are necessary to improve MAT options for clinicians and patients.  In the area of medication options, we believe that more should be done to improve the therapeutic options available to clinicians as they treat patients for opioid use disorder. 

Buprenorphine products have demonstrated clinical efficacy in treating individuals with opioid addiction. There are now several FDA approved medications which each work differently and exist in several forms, strengths, and routes of administration.  Physicians treating AHCCCS members with opioid use disorder should be able to take advantage of the growing number of therapeutic options and be able to select the optimal medication in consultation with their patient.

The current PDL for AHCCCS members provides one buprenorphine treatment option: Suboxone film. While this medication may be the best currently available FDA approved option for many patients, evidence suggests that other patients may respond more positively to some of the other alternatives that are now FDA approved.

While “non-preferred” MAT options can be obtained by physicians via pre-authorization for Medicaid members, the process represents an unnecessary barrier to treatment. Time is of the essence when treating patients with opioid use disorder, and delays between when an individual decides to seek treatment and begins his/her regimen can reduce the likelihood of treatment success.

In summary, we ask that the Pharmacy & Therapeutics Committee recommend that AHCCCS open the Preferred Drug List to additional FDA-approved MAT medications.  When evaluating the list of FDA approved medications for the Preferred Drug List, we urge the Committee and AHCCCS to take into consideration the various FDA approved forms, strengths, and routes of administration as well as individual medication risks for diversion and accidental poisoning. 

Using those criteria, we believe the Committee can responsibly recommend an expansion of the MAT Preferred Drug List for treating AHCCCS members with an opioid use disorder that would improve outcomes for Medicaid members with an opioid use disorder.

We commend the Governor, our state legislators, and the staff at the ADHS and AHCCCS for recognizing the public-health threat posed by opioid abuse and taking concrete steps to implement evidence-based interventions to save lives.  Expanding options for MAT would be an additional concrete step toward that end.

Will Humble State Legislature, Wills Blog

Legislative Update

Not a ton news since last week. I’m beginning to sound like a broken record.

On the e-cigarette and smoking front, the good bill (HB 2357) remains in limbo- as it’s passed the full Senate and got through it’s Conference Committee- but wasn’t called to the floor of the House for a vote again this week.

The competing- not so good bill- SB 1147 passed on a voice vote through the Committee of the Whole in the House- but didn’t make it to a floor vote this week. 

Other than that, legislators are mostly focused on the budget negotiations.  There are a few items we’ll need to ask you to press for in the next couple of weeks with the legislators in your district including:

1) preventative and comprehensive oral health services for pregnant Medicaid members;

2) increased investment in funding for the state loan repayment program and health profession residencies (especially for primary care); and

3) funding Kids Care.

In addition, there’s an important $65M appropriation of federal funds that needs to be made to provide additional subsidies for child care services for folks that qualify- along with a needed increase in reimbursement rates. No state dollars are needed- simply an appropriation of the federal funds that have been allocated to AZ.

Will Humble Tobacco, Wills Blog

A Tale of 2 Vape Bills

This week featured a dual between bills that say their goals are to address the vaping epidemic.  One does and one doesn’t.

The Good Bill

This week the Senate approved (29-0) a bill from Senator Carter (a strike amendment HB 2357) that would classify vaping products in the same category as tobacco.

That means vape pens and the like would be subject to the same laws and rules that govern sales and where you can use them (e.g. vaping would be covered under the Smoke Free Arizona Act). It would also continue to allow cities and towns to impose their own stricter regulations.   HB 2357 would continue to keep the sale age at 18 (rather than 21 which would be ideal) but it would still allow communities to adopt and keep their own ordinances which have raised the age for the purchase of tobacco and vaping products to 21.

After passing the Senate unanimously (as the e-cig version) it went to a Conference Committee a couple of days ago and passed through unanimously. Looks like it’ll be up for a floor vote on Monday in the House.

Now would be a great time to get with your 2 Representatives and let them know you support 2357 because it’s a common-sense bill that defines e-cigarettes as a tobacco product and would remove vaping from public spaces, workplaces and schools.

The Not Good Bill

The tobacco bill dualing for attention is SB 1147 (a different striker bill) which I blogged about last week.  It would set the minimum age statewide for tobacco possession at 21 but it would override lots of other local ordinances about how tobacco and vaping products could be sold and would allow only “reasonable” zoning regulations about where sales can take place.

Another bad thing about SB 1147 is that e-cigs would be in a separate legal category from tobacco meaning it would specifically exempt vaping products from the Smoke Free Arizona Act (vaping didn’t exist when the Smoke Free AZ Act passed in 2006).

This one will likely see a House floor vote next week too.  If it passes it would also need a conference committee because the original Senate version was completely different (about city development). If it gets through the conference committee- it would need another Senate floor vote.

Will Humble Affordable Care Act, Behavioral Health, State Legislature, Wills Blog

Legislative Update

Not a ton news since last week. The main thing that happened this week is that the Governor signed a good bill on suicide prevention (more info below). He also signed a bill that will make Association Health Plans more available in AZ. Info on that below too.  Last week’s  Legislative Update covers things pretty well so far.

Other than that, we’re moving full force into the budget negotiations process now. By all accounts it looks to be a more deliberative process than in years past because of the tight party affiliation margins and the disconnect between the executive budget priorities and those of the legislature. It’s likely that we’ll have at least a few more weeks before a final budget is complete- and it might even go into June this year. 

SB 1468 Suicide Prevention Training

It will require school districts, charter schools, and Arizona teacher training programs to include suicide awareness and prevention training in their continuing education curricula.  It’ll require AHCCCS to make suicide awareness and prevention training available (fortunately some evidence- based tools curricula already exist).

Starting in the 2020 school year, school districts and charter schools would need to provide training in suicide awareness and prevention to school personnel in grades 6 to 12.  The bill also establishes requirements for suicide awareness and prevention training and specifically says that the training use evidenced-based training materials and instruct participants on how to identify the warning signs of suicidal behavior in adolescents and teens.

SB 1085 Association Health Plans (AzPHA Opposed)

This bill was passed by the House this week and is awaiting the Governor’s signature.  He’s sure to sign it. It basically provides a regulatory structure at the state level to regulate AHPs in AZ – serving to make them more available in Arizona. A primary concern for folks interested in public health and consumer protection is that AHPs don’t need to cover the essential health benefits, they can charge differently depending on gender and age. 

Additionally, we’re concerned that if an employer offers a “skinny” benefit plan that barely meets the definition of minimum value (and doesn’t include important essential health benefits) families could be prevented from benefitting from the subsidies that would otherwise be available to them on the Marketplace.

Back in August (at the direction of the President) the US Department of Labor issued a final rule that established criteria for determining when employers can join in an association and be treated as an employer sponsor of a group health plan.  The federal regulation loosens the rules for additional plans to come onto the market, allowing more small businesses including individuals who work for themselves to join these plans.  This bill will make these plans more available in AZ.

Will Humble Medicaid, Social Determinants, Wills Blog

Leveraging Managed Care Contracts to Address Social Determinants

Medicaid programs across the country and our own Medicaid agency (AHCCCS) are increasingly considering how best to address the social factors, such as housing, healthy food, and economic security, that can affect health and medical expenditures (social determinants).

That’s because social determinants of health drive as much as 80% of population health outcomes.  It’s easy to see why there’s such an interest in addressing social determinants as Medicaid program administrators look for ways to contain costs.

Many Medicaid programs including ours have focused much attention on the social determinants that drive costs in expensive or high needs populations (e.g., people with disabilities or a mental illness or HIV/AIDs)… but as the knowledge about how profound social determinants are in terms of costs overall, many are now thinking about how they can address social determinants across the general Medicaid population.

An organization called State Health and Value Strategies has developed an Issue Brief that explores practices states are using to address social factors using Medicaid 1115 waivers and in their managed care contracts The issue Brief also includes steps states can take to implement these practices.

The issue brief includes a review of Medicaid managed care contracts in 17 states and Medicaid 1115 provisions in 6 states.  There are quite a few examples in the report- so I’ve just picked a couple to give examples:

Aligning financial incentives to support SDOH interventions.  States are deploying a range of tools to strengthen the financial incentive for plans to address SDOH. These include the use of withhold payments linked to SDOH-sensitive outcomes and allowing plans to count investments in high-impact social services toward the numerator of their medical loss ratio (MLR).

Creating opportunities for affordable housing. Medicaid does not directly pay for housing, but states are increasingly identifying new ways to connect people to housing resources; providing housing-related services that can be covered via Medicaid; and encouraging their Medicaid managed care plans to participate in broader, cross-sector initiatives to address the affordability and safety of housing.

Building a stronger network of community-based organizations and collaboration with providers. Recognizing that many community-based organizations operate on tight budgets and lack experience contracting with health care plans and providers, states are investing in community-based resources and fostering stronger working relationships between such organizations and health care plans/providers.

Will Humble Medicaid, Social Determinants, Wills Blog

Coding the Social Determinants

ICD-10 diagnosis codes that relate to the Social Determinants of Health can be a valuable source of information to improve health outcomes.  Social Determinants of Health codes can identify the conditions in which people are born, grow, live, work, and age like education, employment, physical environment, socioeconomic status and social support networks- data that can provide managed care organizations information with which to improve outcomes and reduce costs.

AHCCCS is recommending that providers routinely screen for and document the presence of social determinants (as appropriate within their scope of practice) and to document them in claims data. They began monitoring claims for the presence of the codes about a year ago.  You can review the Social Determinant ICD-10 Codes on the AHCCCS website.

Will Humble Prevention, Tobacco, Wills Blog

How Much Compromise is Too Much?

That’s the basic question regarding a bill that is progressing that would move the buy age for tobacco products including e-cigarettes to 21 – but would also pre-empt existing and future local regulation of tobacco products (including e-cigs).

AzPHA has been a long-time supporter of legislative changes to move the tobacco buy age to 21 from the current 18. There is a ton of medical and population-based evidence suggesting that moving the buy age to 21 would be an effective tool for reducing the number of people addicted to nicotine and tobacco – saving many lives.  Tobacco smoking remains the number one preventable cause of premature death (although obesity is expected to overtake tobacco in the next few years).

Our preference has always been to implement a “tobacco 21” law that would cleanly move the buy age for tobacco and e-cigs to 21.  Clean in the sense that the bill would do just that- and not impair cities, towns, universities etc. ability to be more restrictive.

A great example of that is Senator Carter’s SB 1363 which would have cleanly moved the buy age for both e-cigs and tobacco to 21.  We wholeheartedly supported that bill.  Sadly, it never even got a hearing in the Senate because it was assigned to the Commerce Committee instead of Health Committee- and the Commerce Chair didn’t hear the bill.  So, a couple of months ago it looked like a tobacco 21 bill was dead again this session.

Then, last month, along comes a “strike all” amendment to SB 1147 by Senator Allen which also would raise the buy age to 21 but also includes a pre-emption clause preventing any other jurisdiction from implementing tobacco or e-cig control measures that aren’t included in the 1147 bill and that aren’t covered in the Smoke Free Arizona Act. 

The preemption pieces would effectively open up currently tobacco free campuses to anyone over the age of 21 and would allow for vending machines containing e-cigarettes and conventional tobacco in areas where kids could have access to them.  Here are examples of what the pre-emption clause of 1147 would:

Void Phoenix, Tempe and other cities’ zoning boundaries for tobacco retailers that prohibit the sale of tobacco products within 1,320 ft of a school, park, day care facility, among others public places.

Remove local prohibitions on tobacco marketing and advertisements on or near public property, such as near schools, bus stops, park benches.

Eliminate licensing requirements for retail tobacco establishments.

Allow tobacco vending machines in liquor stores where minors can enter without anyone verifying their age. Currently, some cities only allow vending machines in bars that ID customers to ensure they’re 21 and specialty clubs that require membership. 

On the penalty side- SB1147 would create new criminal penalties on those 18-21 rather than primarily placing the penalties on the establishments that sell to people under 21.

The challenge for organizations like ours when deciding whether to support or oppose SB 1147 is to weigh whether the benefit of the 21 buy age intervention is outweighed by the downside posed by the pre-emption.

To be honest- when I read SB1147 for the first time (after the amendments) I was on the fence about whether we should support the bill.  It sure was tempting to get T-21 finally into state law.  But in the end, we decided to stick with the rest of the public health community and oppose the bill for good reasons- because the pre-emption pieces and the fact that the bill doesn’t classify e-cigs with tobacco products really move the balance of the bill as a negative. 

Maybe in the next couple of years we can get a bill that won’t have pre-emptions, would have a more balanced set of penalties, and would include e-cigs in the definition of tobacco products.

So that’s the reason for the title of this piece.  How much compromise is too much compromise- and as a secondary thing- how patient should one be to hold out for a clean intervention.  

I have no doubt that we will eventually get a clean T-21 bill through the legislature.  The question is how many years it’ll take.  Hopefully not as many as it took to get the hands-free cell phone law that was just passed and signed.  That took too many years.  Way too many.

SB 1147 is being heard on Monday in the House’s Committee of the Whole and it could even go to a 3rd read the same day (the Committee of the Whole is the last chance to amend measures in either chamber before bills go to the floor for a 3rd read- which is the floor vote).  Even if it passes the House this week it’ll still need to go back to the Senate because it’s a strike all bill.

Will Humble Assurance & Licensure, Behavioral Health, Public Health, State Legislature, Wills Blog

Legislative Update: May 6, 2019

Legislative Update

We’re moving full force into the budget negotiations process now. By all accounts it looks to be a more deliberative process than in years past because of the tight party affiliation margins and the disconnect between the executive budget priorities and those of the legislature. It’s likely that we’ll have at least a few more weeks before a final budget is complete- and it might even go into June this year. 

Public Health Bills Signed by the Governor

SB 1165 now HB 2318 Hands Free Cell Requirement 

This bill was a long time coming- but were on the precipice of having this good public policy finally happen- all that’s left is for the Gov to sign it. It will prohibit using a hand-held cell phone while driving.  There are some common-sense exemptions for example if the person is using it hands free etc.  It’ll change driving behaviors and save lives.

Violations are a civil money penalty (no driving points) with the first offense being between $75- $150 and the 2nd offense between $150 and $250.  The bill would provide a state overlay so the cell phone use laws would no longer be different from jurisdiction to jurisdiction. Warnings for a year and a half – and then the penalties kick in.

 

SB 1247 Residential Care Institutions

This good bill will require more robust staffing background checks for facilities that provide services for children and will remove the “deemed status” designation for child residential behavioral health facilities. 

Under the old law law, facilities in this category (e.g. Southwest Key) can be accredited by a third party (e.g. Council on Accreditation) and avoid annual surprise inspections by the ADHS.  This intervention will provide more oversight to ensure background checks are done and that the facilities are compliant with state regulations. 

SB 1211 Intermediate Care Facilities

Like SB 1247, this bill closes a licensing loophole. This good bill will require more robust staffing background checks for facilities that provide services to people with disabilities at intermediate care facilities. 

These facilities would also require a license to operate from the Arizona Department of Health Services beginning on January 1, 2020.  Under current law these facilities (Hacienda de los Angeles and similar facilities run by the ADES are exempt from state licensing requirements).

 

SB 1040 Maternal Mortality Report

This bill was signed by the Governor this week.  The new law will establish an Advisory Committee on Maternal Fatalities and Morbidity.

It requires ADHS and the Committee to hold a public hearing to receive public input regarding the recommended improvements to information collection concerning the incidence and causes of maternal fatalities and severe maternal morbidity and complete a report (including recommendations) by the end of this year.

SB 1089 Telemedicine

This week the Governor signed this bill will improve healthcare access and help lower costs. With this legislation, any healthcare service covered in-person by a commercial insurer will also be covered when provided through telemedicine. Currently, Arizona law limits telemedicine coverage to a handful of medical services.

HB 2488 Veteran Suicide Annual Report (Lawrence)

Requires ADHS (starting this year) to complete an annual report on veteran suicides in Arizona that includes the number and rate of veterans who died by suicide, trends, an analysis of the years of potential life lost, a comparison of Arizona’s resident veteran suicide rate to those of the nation, and the relative risk of suicide by race or ethnicity, age group, gender and region. 

The report is also supposed to analyze patterns of drugs, or combinations of drugs, that were used by Arizona’s resident veterans when drug poisoning was the mechanism of suicide. The idea is to create the surveillance and data linkages needed to inform suicide prevention strategies based upon medical risk factors that significantly correlate to suicide.

SB 1109 Short Term Limited Health Plans- extension – AzPHA Position: Opposed

This bill has passed both chambers and has been signed by the Governor.  It authorizes the sale of short- term limited health plans in Arizona for terms up to 3 years.  The previous limit was 1 year.  These plans don’t cover pre-existing conditions and have limited consumer protection because they aren’t required to cover the essential health services under the ACA and can drop enrollees.  We urged a not vote because of the poor consumer protections.

On the Governor’s Desk for Signature

 SB 1468 Suicide Prevention Training

This good bill is awaiting the Governor’s signature.  It will require school districts, charter schools, and Arizona teacher training programs to include suicide awareness and prevention training in their continuing education curricula.  It’ll require AHCCCS to make suicide awareness and prevention training available (fortunately some evidence- based tools curricula already exist).

Starting in the 2020 school year, school districts and charter schools would need to provide training in suicide awareness and prevention to school personnel in grades 6 to 12.  The bill also establishes requirements for suicide awareness and prevention training and specifically says that the training use evidenced-based training materials and instruct participants on how to identify the warning signs of suicidal behavior in adolescents and teens.

SB 1085 Association Health Plans (AzPHA Opposed)

This bill was passed by the House this week and is awaiting the Governor’s signature.  He’s sure to sign it. It basically provides a regulatory structure at the state level to regulate AHPs in AZ – serving to make them more available in Arizona. A primary concern for folks interested in public health and consumer protection is that AHPs don’t need to cover the essential health benefits, they can charge differently depending on gender and age. 

Additionally, we’re concerned that if an employer offers a “skinny” benefit plan that barely meets the definition of minimum value (and doesn’t include important essential health benefits) families could be prevented from benefitting from the subsidies that would otherwise be available to them on the Marketplace.

Back in August (at the direction of the President) the US Department of Labor issued a final rule that established criteria for determining when employers can join in an association and be treated as an employer sponsor of a group health plan.  The federal regulation loosens the rules for additional plans to come onto the market, allowing more small businesses including individuals who work for themselves to join these plans.  This bill will make these plans more available in AZ.

Will Humble Prevention, State Legislature, Wills Blog

New Study Shows Positive Economic Impact from SB1354

It’s been clear from the start that SB 1354 – the most important access to care bills this year- would do a great deal both in the short-term by boosting the primary care loan repayment program and really enhance graduate medical education residencies over the coming years (important because where a practitioner does her or his residency greatly influences where they ultimately practice).  Arizona’s primary care physician shortage is one of the worst in the nation (meeting only 42% of the state’s needs).

The public health merit of a bill is often not enough to carry the day – especially when a financial appropriation is involved- because the return on investment matters too.  Fortunately, the Arizona Hospital and Healthcare Association and the Arizona Rural Health Association commissioned a study to measure how SB 1364 would affect the economy and patient access to care.

The result of the independent economic impact study found that the SB 1354 investments would have a “significant positive economic impact” to the state and expanded patient access to care over the next ten years.

The report found that the bill would enable hospitals across the state to increase the number of post-graduate physician residents they train and found that increasing the number of physician residents at three rural hospitals alone would result in 845 new high- paying jobs and $911 million in economic output over ten years.  Additionally, the bill lessens the issue of physicians leaving Arizona after graduation because they are unable to secure the limited amount of in-state residency positions.

Almost 75% of medical students who finish post-graduate training in Arizona stay in Arizona. This means state funding for physician residencies will move the needle on the state’s physician shortage and be a game-changer for rural communities.

The bill sailed through the Senate but stalled in the House – as the Rules Committee never heard the Bill (and that committee is no longer meeting).  But- portions of the bill or even the whole bill could be included in the final budget as what’s called a Budget Reconciliation Bill or BRB.

Will Humble Affordable Care Act, Wills Blog

US Justice Department Files its Argument Against the ACA

A few months ago a federal judge in Texas (Judge Reed O’Connor) dealt a blow to the ACA when he ruled in Texas v. Azar that the ACA is unconstitutional in its entirety…  including the implementation of market reforms (e.g. protections for folks with pre-existing conditions), the health insurance marketplaces, and the expansion of Medicaid. He didn’t issue an injunction ordering the suspension of the law – so the ACA will remain the law of the land for now.

The DOJ made it clear that they have no intention of defending any of the provisions of the ACA (including covering pre-existing conditions) because they agree with the plaintiff States. That message came in a short statement by the Attorney General when he notified the court that they fully side with Judge O’Connor’s decision in Texas v. Azar & won’t defend the ACA.

This week the Department of Justice filed their argument against the ACA with the court. The government argues that since the “individual mandate” has now been effectively eliminated by the tax overhaul law last year the whole ACA unconstitutional.

Last week’s filing concedes that the administration had previously argued that parts of the ACA could remain in effect even if the individual mandate were struck down, but they are changing that position now and their position is that the court should strike down the law in its entirety.

Because of the makeup of the 5th Circuit Court of Appeals, the court will likely uphold O’Connor’s decision and the case will probably end up with the US Supreme Court…  which has a different cast of characters than it did when the ACA was originally upheld back in 2012 by a 5-4 vote.

Since then, Gorsuch replaced Scalia and Kavanaugh replaced Kennedy.  Both Scalia and Kennedy voted against the ACA- so not much on that score has changed.

Chief Justice Roberts voted with the majority that upheld the law.  His argument rested on the ACA’s link to the financial penalties for not having health insurance. But remember, the financial penalties for not having health insurance were removed from the IRS tax codes in last year’s federal tax overhaul, pulling out the structure that Roberts used in his argument.

In the 2012 Ruling, Justice Roberts wrote that: “… the Affordable Care Act’s requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax… because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.” 

Roberts rejected the Administration’s argument that the federal government’s authority to regulate interstate commerce provides the authority needed for the ACA to be constitutional (the Court struck down that argument 5-4).

The bottom line is that the ACA, including its protections for folks with pre-existing conditions, may very well be in jeopardy if Roberts views the ACA as fundamentally different now that the financial penalties are gone.

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