Will Humble Family Planning, Federal Public Health Bud, Maternal Health, Prevention, Wills Blog

New Funding Opportunity Available for Arizona to Explore Strategies to Reduce Maternal Mortality

A couple of months ago (before the government shutdown happened) landmark federal legislation was passed and signed that will provide millions of dollars to help states determine why women are dying from pregnancy and childbirth at troubling rates.  

The new funding is great news because studies have found that at least half of childbirth-related deaths could have been prevented if health care providers had followed best medical practices to ensure complications were diagnosed and treated quickly and effectively.

The bill provides $12M in annual funding to the CDC to pass through to states with maternal mortality review committees and create committees in the 12 states that lack them.  Arizona has a committee in statute because of a law signed in 2011 – here’s a link to the most recent report.

In order to qualify for funding, states need to demonstrate  that their “methods and processes for data collection and review use best practices to reliably determine and include all pregnancy-associated deaths and pregnancy-related deaths, regardless of the outcome of the pregnancy.” All indications are that the ADHS meets these CDC data standards and therefore would qualify for funding.

We and the Arizona Chapter of the March of Dimes will keep an eye out for the grant announcement and offer any assistance that the ADHS needs with their application for this important funding opportunity that can be used to save the lives of Arizona moms.

Will Humble Affordable Care Act, Family Planning, Federal Public Health Bud, Maternal Health, Medicaid, Wills Blog

Maternal Mortality: A Tragic Trend Continues in the US and AZ

The US has the highest maternal mortality rate of any developed country.  Sadly, it’s getting worse each year.  About 800 American women die and 65,000 almost die during pregnancy or childbirth.

The number of deaths in AZ jumped from around 10 in 2015 to about 30 in 2016 (the last year for which ADHS has data posted). The numbers are rounded for statistical reasons (called cell suppression in the public health statistics trade.)

Nationally, back women die from pregnancy-related causes at three to four times the rate of white women, even after controlling for social determinants. Women in rural areas also have higher maternal mortality rates than urban women.  Here’s a story that highlights some of the issues in an easy to read way.

Fortunately, there are public health policy leverage points that can make a difference within state health departments and Medicaid agencies.  Medicaid is a leverage point because it pays for over half of all births each year in 25 states including Arizona.  

All states provide Medicaid coverage for women with incomes up to 133% of poverty during pregnancy and for 60 days after delivery.  But the scope of services covered before and after delivery vary between states.  As a result, some women lose coverage or Medicaid eligibility in certain states after that 60-day period (mostly in states without Medicaid expansion).

In Medicaid expansion states (like AZ) women have more opportunities to achieve better preconception health because they’re more likely to be able to access contraception and plan their pregnancies, receive primary care services to manage chronic conditions prior to and between pregnancies and access prenatal and perinatal care once pregnant.

Evidence-based policy making is a key.  Twenty-nine states (including Arizona) have committees that review maternal deaths and make public policy recommendations.  Back in 2011, Arizona passed, and the Governor signed a bill that amended our child fatality review statutes by adding reviews of maternal deaths.

The statute charges our existing Child Fatality State Teams to review maternal deaths (called the Maternal Mortality Review Subcommittee) and make policy recommendations. The primary goal is to identify preventive factors and make recommendations for systems change. The existing statute doesn’t require an annual report- and the last report was published in 2017. Note: we’ve heard that there may be a Bill this session that will require an annual report of the committee’s work.

Here are some of the recommendations from the most recent ADHS report (published in 2017):

  • All pregnant women should have access to prenatal care;

  • Encourage maternal care professionals, organizations, and health facilities to update their standards of practice and care to include all recommended guidelines for the prevention of medical complications;

  • Promote public awareness of the importance of healthy behaviors and women’s overall health prior to pregnancy;

  • Women should always wear proper restraints when riding in cars;

  • Maternal health-care systems require strengthened, prepared, and educated communities to improve deliveries in health facilities, particularly in rural areas;

  • Increase and streamline access to behavioral health services statewide, including training and education for advanced practice nurses in behavioral health services;

  • Support and implement community suicide prevention and awareness programs, such as Mental Health First Aid;

  • Health care providers should screen frequently for perinatal depression and domestic violence;

  • Institute and follow recommended California Maternal Quality Care Collaborative guidelines (www.cmqcc.org) for the timely transfer and transport to a higher-level care facility for any complications using regional transport services; and 

  • Educate providers on the availability of maternal postpartum resources such as home visiting programs.

Some states have gone further. For example, South Carolina’s Medicaid agency formed the South Carolina Birth Outcomes Initiative to advance reductions in early elective deliveries; incentivize Screening Brief Intervention and Referral to Treatment; promote long-acting reversible contraception; and support vaginal births.  One outcome of the SC initiative was to reimburse for long-acting birth control (LARC) devices provided in a hospital setting. 

Fortunately, Arizona has also included LARC reimbursement in a hospital setting post-partum.  This is an important policy intervention because it provides women with a long-acting and reversible option, so they can better plan future pregnancies – improving opportunities for preconception health, which is a key to improving health outcomes.

Will Humble Medicaid, Social Determinants, Wills Blog

The Intersection of Public Health and Housing

Affordable, safe, and stable housing directly impacts an individual’s health and well-being and improves people’s ability to manage chronic diseases and mental conditions, access education and employment, and build healthy relationships.  Persons that are homeless face illness at three to six times the rate of housed individuals and are three to four times more likely to prematurely die than the general population.

Ensuring that patients have stable housing can also reduce healthcare costs.  An analysis of Oregon Medicaid claims data found people placed in stable and affordable housing reduced their overall Medicaid expenditures by 12%. Housing placement also correlated with a 20% increase in primary care visits and an 18% decrease in emergency department visitations among Oregon Medicaid members. 

It’s no surprise then that hospitals and health systems are increasingly interested in supporting access to stable and quality housing as a strategy to reduce downstream healthcare spending, especially as they move toward value-based payment models.

CMS is catching on too.  A couple of years ago they released a bulletin emphasizing the importance of designing Medicaid benefits packages that incorporate the social determinants of health. They outlined allowable coverage of housing-related activities and services for individuals with disabilities and older adults requiring long-term services and supports, like conducting individual tenant housing assessments, assisting with the housing search and application process, or offering tenancy sustaining services.

Last month the HHS Secretary suggested that CMS will be introducing a payment model allowing hospitals to directly pay for housing and other social services using federal Medicaid dollars. The statement suggests that this shift stems from a broader interest in better alignment between health and human services and that such a model would be tested by the Center for Medicare and Medicaid Innovation (CMMI).

While direct spending on room and board still isn’t allowed under the Medicaid statute, several state Medicaid programs are pursuing demonstration waivers that allow for innovations or flexibilities in Medicaid-managed care programs to address housing needs or other social determinants of health.

North Carolina recently received approval of its Section 1115 waiver which will allow their Medicaid managed care contractors to cover evidence-based, non-medical interventions that have a direct impact on members health outcomes and costs. The pilots will be implemented regionally to address housing, food security, transportation, employment, and interpersonal safety. I think North Carolina is the first state to receive this type of waiver, but I’m not 100% sure about that.

CMMI is also exploring the impact of screening and referrals for health-related social needs (including housing) of Medicaid and Medicare dual beneficiaries. They’ll be measuring whether screenings and referrals to community-based organizations and social services generate improvements in health outcomes and reductions in healthcare spending. The model is being piloted through 31 organizations in 23 states including at AHCCCS.

Will Humble Federal Budget, Federal Public Health Bud, Public Health, Public Health Law, Return on Investment, Social Determinants, Wills Blog

‘Opportunity Zones’ & Public Health

When you think about the tax bill passed by congress last year you probably think about the permanent reduction in corporate tax rates and changes in the person income tax standard deductions and stuff like that.  But there was a sleeper provision in the law that could influence the built environment and therefore public health.  It’s a provision in the law called ‘Opportunity Zone’ investment tax deferment.

The ‘Opportunity Zones’ part of the new tax law provides incentives to investors to put their money into areas designated by states as low income or underdeveloped.  The law lets investors defer (or eliminate) their capital gains tax obligation when they invest the money in a designated ‘Opportunity Zone’. If they hold the investment for 7 years, 15% of their capital gains liability can be written off.  If they hold the investment for 10 years, then their entire capital gain tax liability can be written off.

The theory is that geographically targeted tax cut opportunities will encourage new clusters of economic activity to form which has the potential to improve conditions that influence the social determinants of health within the designated ‘Opportunity Zones’.

There are very few conditions that are put on the program in terms of what is a qualifying investment, except that the investment must be within a state designated Opportunity Zone.  Developers must make a substantial improvement on the property in the first 30 months.  Investors need to show that 70% of their capital is in the opportunity zone and 50% of their activities.

The governor of each state decides where the Opportunity Zones are (they can name 25% of the qualifying low-income Census tracts as Opportunity Zones).  Our Governor delegated that decision to the Arizona Commerce Authority.  Arizona’s Opportunity Zone nominations were submitted to the US Treasury Department a few months ago and have already been approved.  Here’s the map of the Opportunity Zones Arizona selected.

A couple of months ago the U.S. Department of the Treasury released their guidance on the Opportunity Zone tax law provisions.  The Internal Revenue Service issued proposed regulations in October. 

The AZ Commerce Authority has some material on their website with a more in-depth view of Opportunity Zones including a Guidance Update Webinar Presentation and an Opportunity Funds Guidance Update Webinar Video October 2018.

One thing is clear- the incentives built into the Opportunity Zone parts of the tax bill are huge- and there will be billions of dollars moving into these Opportunity Zones in the coming years.  What remains to be seen is what impact the program will have on the built environment and economic opportunities in these areas and what public health impacts will occur – both good and bad – as a result of the investments that are made in these communities. 

Very few guardrails exist for what kinds of developments qualify for the tax deferral- and no doubt there will be some good things (affordable housing) and bad things (investments that don’t improve conditions) in Opportunity Zone communities in the coming years.

Will Humble Medicaid, Wills Blog

Jami Snyder Appointed AHCCCS Director

Jami Snyder was appointed to the post of the Director of AHCCCS effective this Friday.  She has been serving as the as deputy director of AHCCCS since December of 2017. Prior to that she was the Medicaid Director in Texas and as Chief Operating Officer of the University of Arizona Health Plans. She also previously held posts as  a Bureau Chief at the Arizona Department of Health Services. 

Jami is a 2013 Flinn-Brown Civic Leadership Academy Fellow, and graduated with a BS in political science from Gustavus Adolphus College and went on to earn a master’s degree in political science from ASU.

I really think Jami is a terrific choice for this important job. She has a good reputation in the public health world and is known as somebody that understands the linkages that public health and health care can forge in designing and implementing interventions that improve public health outcomes while reducing costs.

Congratulations Director Snyder! 

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