Shelby Air Quality, Climate Change

Clean Energy Rules Go Down the Drain

The Arizona Corporation Commission voted down the clean energy rules last week. Those rules, had they been adopted by the Commission would have required state-regulated utilities to get 100% of their power from carbon-free sources by 2050.

Back in April, the Administrative Law Judge presiding over the formal rulemaking issued her recommended opinion and order which recommended approving the rules.

At the May 5 meeting, Commissioner Olson proposed amendments that would have changed the Rule’s requirements for carbon-free electricity, energy efficiency, peak demand reduction, and distributed storage into voluntary goals. The amendment was supported by Chairwoman Marquez Peterson and Commissioner Jim O’Connor.

Once that amendment passed, Commissioners Sandra Kennedy and Commissioners Anna Tovar voted with Olson against the full Rules package (which had become meaningless really) and the entire package failed by a vote of 3-2.

AzPHA, environmental organizations, utilities, industry, and consumer advocates had all aligned  in support of the Rules as originally drafted and we all expressed their disappointment with the Commission outcome on social media.

This very disappointing outcome came after years of work, multiple public meetings and workshops, dozens of supportive studies, and thousands of public comments all in support of the Rules as originally drafted.

Before the Commission’s vote took place,~30 diverse public commenters including large businesses, faith leaders, and more urged the Commission to move forward with the Rules expeditiously and without amendment.

This isn’t the end. The good work that all the stakeholders did to get this going still exists. The question becomes what strategy to use next.

Shelby Healthcare

Landmark Telemedicine Bill Big Boost to Access to Care

In some ways Arizona has been leading the way in terms of leveraging telehealth as a means of improving access to care. The UA Telemedicine program was established 25 years ago and has successfully built infrastructure and partnership agreements that has laid groundwork to bring telehealth to the next level.

COVID-19 provided a big push to use telehealth in a more widespread way, including within AHCCCS. Executive orders early on pushed health plans to pay for appropriate telehealth services. A new law passed and signed last week (HB 2454) locks in telehealth services for the future, expanding statewide use of virtual video and audio doctors visits.

It’s a long bill – but the opening line gives you a sense of what it does:

All contracts issued, delivered or renewed on or after 7 January 1, 2018 in Arizona must provide coverage for health care services that are provided through telehealth if the health care service would be covered were it provided through an in-person consultation encounter between the subscriber and a health care provider and provided to a subscriber receiving the service.

The new law:

  • Ensures doctors receive equal compensation from insurance companies for telehealth services.

  • Allows out-of-state health care providers to practice telehealth in Arizona.

  • Ensures payment parity for audio-only medical visits for patients without internet access.

  • Prohibits health care boards from enforcing any rule that requires a patient to visit in-person before being prescribed most medications.

Importantly, there are no exemptions for our Medicaid program, so telehealth can become an increasingly important way to reduce health disparities especially in rural and underserved areas with thin network access.

Perhaps Dr. Ronald Weinstein (founding director of the University of Arizona’s Arizona Telemedicine Program and a president emeritus of the American Telemedicine Association) said it best in this article from the Arizona Republic yesterday:

The UA’s Arizona Telemedicine Program is 25 years old, but telehealth has been around even longer, Weinstein said. Until the pandemic, efforts to get telehealth more widely used have been hindered by regulations and reimbursement challenges, he said.

“It’s really been held with a brake on it for 50-plus years and waiting to be proven,” he said. “COVID came along, and social distancing and so forth, and within a month the amount of telemedicine being done in the United States went up about 3,000%.”

The rapid removal of the regulations and fragmented payments that had been holding telehealth back is what Weinstein calls an interesting example of innovation acceleration.

“What are the major things that are innovation acceleration? Natural disasters, pandemics and wars,” Weinstein said. “Digital medicine has moved ahead 10 years within the period of a month.”

One of our breakout sessions at our August 26 AzPHA Annual Conference will focus on the future of telehealth in Arizona’s Medicaid program AHCCCS.

Shelby Disease Control, Vaccination

New CDC Guidance Says Fully Vaccinated Folks Can Get Back to Normal

DID CDC MAKE THE RIGHT CALL?

The CDC released new guidance today for folks that are fully vaccinated with the basic message that if you’re fully vaccinated, you can basically get back to pre-pandemic behavior. Today’s guidance says that fully vaccinated people can resume activities without wearing a mask or even physically distancing including in local business and workplace guidance (like healthcare facilities and where local rules still require masks).

Is this the right call? I think it is.

The CDC waited to make this policy change until the data were clear about how protective the vaccines are in real life. Importantly, they also waited for a sufficient number of Americans to get vaccinated, ensuring that we won’t have another hospital capacity crisis or even a significant rise in infections.

Will some unvaccinated people claim that they have been vaccinated and go to public places without a mask? Sure they will. Will that kind of behavior create a dangerous environment? Not really, because:

  • So many folks have now been vaccinated now (especially people over 65);

  • We now know that the real-life efficacy of the dominant vaccines is as good or better than what was found in the clinical trials;

  • We have evidence that persons that have been vaccinated are very unlikely to carry or shed the virus to others; and

  • The vaccines are working on all known variants.

I’m hoping that we see a bump in the number of people that get vaccinated because of this announcement. While it’s true that many unvaccinated people will say they are vaccinated in order to not be judged for not wearing a mask in public, many won’t want to. Some folks that have been on the fence will see that vaccines have a tangible real-life benefit and decide to finally go ahead and get vaccinated.

Let’s hope that this added incentive to get vaccinated makes a difference and more people that have been delaying getting the vaccine decide to take the plunge. But even if they don’t, today’s new recommendations are evidence-based, make common sense, and reflect the diminished risk that the virus now poses in the U.S.

Editorial Note: It’s important that we use evidence to drive our decision-making (and avoid making recommendations out of ‘an abundance of caution’). It’s also important for us to weigh risks and benefits when making policy. When we make decisions that are overly restrictive, that aren’t based on evidence, that don’t consider real risks in a clear-eyed fashion, or that don’t consider both the risks and benefits we risk losing our credibility with the public (e.g. we get a reputation for saying that the sky is falling).

Our credibility as a profession is really important because people will only follow our public health recommendations if they view us as reasonable and evidence-based.

P.S. The persons that could potentially be harmed by the CDC’s change in policy are those folks that are immunocompromised. Folks with weakened immune systems may not form a robust immune response after being vaccinated, and will need to keep in mind that some persons that they will see in the community without masks may not be vaccinated.

P.S.S. This virus is still posing and will continue to pose a substantial public health risk in many developing countries for many months and perhaps years to come. Our commitment to COVAX (the international effort to get vaccine to developing nations) is critical- not just because it’s our ethical responsibility as a rich nation to help less wealthy countries acquire vaccine, but also to prevent the virus from boomeranging on us. The more opportunities this virus has to mutate (e.g. worldwide infections) the more likely it is that a new variant will evolve that’s resistant to immunity acquired from previous infections or vaccinations- potentially resulting in COVID-22.

Want to learn more about these recommendations? Read the CDC’s expanded Public Health Recommendations for Fully Vaccinated People.

Shelby Disease Control, Vaccination

FDA Authorizes Emergency Use of Pfizer Vaccine for 12–15 Year-Olds

POLICY AND OPERATIONAL ADJUSTMENTS NEEDED TO ACCOMMODATE ADOLESCENT ROLLOUT

The FDA just authorized the Pfizer vaccine for use in kids 12-15 years old.  Pfizer says in their press release (not via peer reviewed data) that their clinical trial (of 2,260 participants) showed that their vaccine was 100% effective in 12-15 year olds and had minimal side effects.

The CDC’s Advisory Committee on Immunization Practices is meeting Wednesday morning to decide whether to recommend the vaccine’s use in 12-to-15-year-olds (here’s the Agenda and webcast link). CDC Director Dr. Rochelle Walensky will decide whether the agency will recommend its use in the new age group. Most likely, the vaccine will be both authorized and recommended for 12-15 year olds by the end of the week.

There are some tricky things about the logistics of administering the Pfizer vaccine that will require the ADHS to make some adjustments in order to make it easy for adolescents 12-17 to get vaccinated in their medical home (the best place for them to be vaccinated).

For one thing, the Pfizer vaccine can only be held in a normal (-20C) freezer for 2 weeks. In order to store it longer than that, doctor’s offices need to have an expensive ultra-cold freezer (-70C).

Doctor’s offices can usually turn-around their vaccine inventory in 2 weeks but a single standard order of Pfizer vaccine contains about 1,170 doses, too much for a small pediatric office to administer over a 2 week period.

One work-around would be for the county/state health departments to “break down” the big Pfizer order into smaller packages so pediatric and family practices won’t need to commit to such a big order (Pfizer has said that by the end of May they will have smaller minimum order boxes, so that’ll help).

Another issue is that we’ll need more pediatric providers to be able to order the SARS CoV2 vaccine. Up until now, doctors offices need to go through a complex ADHS on-boarding process in order to be able to receive the COVID shot.

A good work-around for that is to allow all Vaccines for Children (VFC) providers to be auto-enrolled in the COVID vaccine program. Easy to do. Let’s hope ADHS is flexible enough to make that happen.

Note: Last week the ADHS finally began to allow doctors offices to order vaccine for their practice. The offer was made to providers that were already on-boarded using their process. Only 65 doctors actually ordered vaccine (see this Arizona Republic story).

ADHS needs to do a root-cause analysis to figure out why so few ordered vaccine last week. Is it the cumbersome ordering process? Poor communication? Unreasonable reporting requirements? A combination? Only by figuring out way last week’s effort failed will they be able to make the policy and operational changes to fix this big problem.

In other news, Pfizer submitted their application for full approval (licensure) of their mRNA vaccine last week. The application review will likely take several weeks. Full approval would provide more assurance to some people that are still holding out that the vaccine is safe.

Shelby Disease Control, Vaccination

Dr. Gerald’s Latest Epidemiology & Hospital Analysis

Dr. Gerald just released his latest epidemiology and hospital capacity report. Below is a summary but as always we encourage you to explore the full report for details.

  • Covid-19 cases and hospitalizations are little changed over the past two weeks. We can expect similar levels of viral transmission for the next 4 – 6 weeks before rates begin to substantially improve.

  • Overall, cases are being diagnosed at a rate of 68 per 100K residents per week- in-between the moderate and substantial spread categories.  Case rates will likely remain “stuck” at around the 50 cases per 100K residents per week for the next 4 – 6 weeks owing to more transmissible variants (e.g., B.1.1.7) and continued normalization of behaviors.

  • Test positivity for traditional nasopharyngeal PCR testing is holding steady at 10%.

  • Hospital Covid-19 occupancy is slowly increasing in the ward and ICU. Access to care remains somewhat restricted as overall occupancy remains unseasonably high (85%) while the backlog of medically necessary non-Covid procedures is being addressed.

  • Arizona continues to slip relative to other states when it comes to the percentage of our population that is vaccinated. Arizona now ranks 40th in vaccines administered per capita.

Note: This is the next-to-last regularly scheduled update. Barring unforeseen circumstances, the last report will be published on May 21, 2021. If you have found this report valuable and would like to send a note of appreciation, please e-mail my Department Chair, Dr. Kelly Reynolds at reynolds@arizona.edu

 UPDATED ASU MODELING TEAM REPORT

The ASU COVID-19 Modeling Group recently updated their model (April 29, 2021) to incorporate vaccination efficacy and increasing prevalence of the B117 variant. This model is based on their prior work charting the course of the COVID-19 outbreak using a traditional SEIR epidemiological model.

To incorporate the impact of vaccines, the model accounts for a differential effectiveness attributable to the first and second dose, 50% and 95% respectively. Vaccination data are derived from the ADHS dashboard at the state-level and does not account for differential rates or outcomes by age.

The model assumes a single homogenous risk pool throughout the state. Furthermore, their model assumes a B117 variant dominance by the end of May with its associated 60% increase in transmission. No changes due to increased behavioral interactions are modeled.

Figure 3A in the report shows their best-case scenario (gold line) where COVID-19 vaccinations continue at a pace of 50,000 vaccinations per day. Under this scenario, case rates will peak and then begin to decline towards the end of May. Clearly, there is little-to-no risk of a no summer resurgence.

Under their worst-case scenario (blue line) where no new vaccinations are initiated after April 28th , case rates will slowly trend upwards and remain in the substantial category (50 – 100 cases per 100K residents per week) through much of the summer.

However, even under this pessimistic scenario, there is little-to-no risk of a summer resurgence on par with June 2020. Altogether, this is really good news.

Shelby Public Health Law, Return on Investment

Optimism Grows Regarding Prescription Drug Pricing Reform

It’s no secret that prescription drug prices in the U.S. are far higher than in other countries and that the current system costs taxpayers, insurance plans and people far more than it should. A huge barrier has been language in the Medicare law prevents HHS from directly negotiating drug prices under the Medicare Part D drug benefit program.

Achieving prescription drug pricing reform (allowing Medicare to negotiate drug prices) has been out of reach for decades because the drug company lobby is so powerful that meaningful reform has been impossible.

That may be changing. President Biden mentioned that one of his priorities include allowing Medicare to negotiate on behalf of people enrolled in Medicare Part D drug plans, a proposal which has strong and bipartisan public support.

The US House of Representatives has already passed a measure called “H.R. 3, the Lower Drug Costs Now Act of 2019” which would require HHS to negotiate the price of between 25-125 brand-name drugs without generic competitors. That negotiated price would be available Medicare, Medicaid and private payers. Importantly, HR 3 also provides some negotiating leverage to HHS.

For one thing, it would establish an upper limit for the negotiated price equal to 120% of the Average International Market price paid by Australia, Canada, France, Germany, Japan, and the UK.

It would impose financial penalties on drug companies that don’t comply with the negotiating process. Manufacturers that fail to negotiate would face an escalating excise tax on the previous year’s gross sales of the drug in question, starting at 65% and increasing by 10% every quarter to a maximum of 95%.

This is such a common sense intervention that would help both Medicare beneficiaries and the Medicare Trust Fund. Let’s hope that there is finally enough support in congress to pass this long needed reform.

Shelby Vaccination

JOHNSON & JOHNSON VACCINE UPDATES

A new MMWR summarizes the decision of the Advisory Committee on Immunization Practices (ACIP) to resume Johnson & Johnson COVID-19 vaccination.

FDA has added a warning to the vaccine EUA and factsheets, and patient education about this risk should continue. Additionally, FDA has published an updated FAQ about the Johnson & Johnson vaccine. For more, see ASTHO’s updated brief on ACIP’s decision to lift the recommended pause on the Johnson & Johnson vaccine.

Shelby Behavioral Health, Suicide Prevention

New Behavioral Health Resource Guide for Arizona Schools

The AHCCCCS suicide prevention team, in collaboration with the Arizona Department of Education School Safety and Wellness team have published a Behavioral Health Resourece Guide for Schools.

The guide is intended for parents, educators, and stakeholders. It has timely information about how schools can partner with behavioral health providers, information about implementation of Jake’s Law (the new parity law that provides services to underserved/uninsured children), a suicide prevention and postvention policy template and more.

The guide is intended to help make accessing services easier for all of Arizona’s students, and to help educators identify what resources may be available for a student in need. The bigger goal is to have all schools in Arizona with a suicide prevention and postvention policy. It is critical schools know how to respond if there is a suicide of a student or staff member, and how to provide follow up care to the community.

For more information about this initiative visit the AHCCCS Website at: https://www.azahcccs.gov/AHCCCS/Initiatives/BehavioralHealthServices/

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