Open Enrollment for the Affordable Care Act Marketplace Goes Through January 15, 2023

Open enrollment has begun for the Health Insurance Marketplace! Spread the word and provide enrollment assistance: learn more. The 2023 Open Enrollment Period runs from November 1, 2022 to January 15, 2023.

Learn more about enrollment basics and FAQs at Healthcare.gov or find helpful state-by-state Medicaid and CHIP enrollment information at Medicaid.gov. Additionally, HHS recently renewed the COVID-19 Public Health Emergency, which will continue through January 11, 2023.

What Impact Will the Election Results Have on Arizona Public Health?

In terms of state legislation – I expect more of the same from the state legislature. But the fact that we have Governor-elect Hobbs on the 9th floor means that we can spend less energy fighting bills that are bad for public health during the legislative session. During the Ducey years we knew we had to stop bills in one of the chambers because he was a sure rubber stamp bad bills. Over the next couple of years, we’ll have checks and balances in the system because of the executive branch which will require less defense.

The real progress in public health over the next couple years won’t be related to legislative action. It’ll be associated with executive branch action. Here’s why.

Governor Ducey had a cap on the number of employees state agencies could have (commonly referred to in state government as the head-count cap). This caused state agencies to decide not to apply for federal grants, because if they get the award, their agency director wouldn’t let them hire the persons necessary to manage the grant.

Governor Ducey also had a ‘moratorium’ on state agency rulemaking, meaning agencies were by and large stuck with the administrative code (regulations) that they have on the books. We hope to see Governor Hobbs lift that moratorium on administrative rulemaking – allowing agencies to modernize their Administrative Code to improve health outcomes and reduce disparities.

We also expect to see persons appointed to agencies that are more in sync with public health principles. Having an ADHS director that sees county health departments as true partners in public health will go a long way in improving the working relationship between state and county and tribal public health.

We also expect there will be far less micromanagement of ADHS…  meaning ADHS staff will feel freer to brainstorm and propose new ways to address health disparities without worrying what a 9th floor that is hostile to public health will think. This healthier environment will also make it easier to recruit talented agency leadership.

We expect the Hobbs Administration will have an easier time recruiting talented folks into state agency and commission leadership positions which will greatly improve the quality of decision-making and execution in state government.

In short…  I’m optimistic that we can make real strides in public health over the next 4 years – because of progress in the executive branch.

Checks & Balances Return to State Government for the First Time Since 2008

Governor-elect Katie Hobbs will be Arizona’s next governor. Her 4-year term will officially begin at Noon on Monday, January 2, 2023. Given her track record and background, we expect to have a public health ally in the governor’s office for the next 4 years.

Governor-elect Hobbs spent many years serving as a social worker and then in the state legislature – often serving on health committees. This is the first time that I can think of when we’ve had a governor that has worked – at the grassroots level – on improving the social determinants of health.

Meanwhile, the state legislature is likely to be less friendly to many of our public health priorities than the executive branch. Both legislative chambers will have the same margins as the last year—31-29 Republican majority in the Arizona House and 16-14 Republican majority in the Arizona Senate.

Both chambers also held internal leadership elections—new Senate President will be Warren Petersen, President Pro Tempore T.J. Shope, Majority Leader Sonny Borrelli, and Majority Whip Sine Kerr. The Senate Health Committee will be chaired by T.J. Shope.

In the House, the new Speaker will be Ben Toma, with Leo Biasiucci as the Majority Leader. Committee chairs in the House have not been announced (as far as I know). If you have questions about other elections—statewide, federal or legislative—check out the Secretary of State’s website.

P.S. I’ll do a summary of the results of the ballot measures and what the results might mean for public health next week.

How Can State Agency Staff Prepare for their Meetings with the Gubernatorial Transition Team?

Doing an Honest SWOT Analysis is a Good Place to Start

Governor-elect Katie Hobbs will likely be announcing details about her gubernatorial transition team shortly. Once the team is established, folks in key leadership positions at the state agencies should prepare in case members of the transition team ask for a meeting.

It’s a 48 Day Sprint to Inauguration Day: Here’s What We Might Expect During the Transition – AZ Public Health Association

How can a person in agency leadership prepare for a meeting with the transition team? Something that’s worked well for me is to develop a SWOT analysis of your area of responsibility and for the agency. Going through a SWOT analysis will give structure to your conversation with the transition team by identifying the internal and external factors that are helping or hurting your effectiveness.

What’s a SWOT analysis? It’s a strategic management technique that identifies agency Strengths, Weaknesses, Opportunities, and Threats. Strengths and weaknesses are generally internal to your agency. Opportunities and threats are more external factors. Here’s a short description of each category.

  • Strengths: characteristics of your organization or division that are working well toward achieving the mission
  • Weaknesses: things that are impairing the ability of the organization to achieve its mission or to excel
  • Opportunities: things in the political or economic environment that the organization could exploit to improve their performance (e.g., things the current or previous administration or leadership was hostile toward that would help reduce health disparities for example)
  • Threats: elements in the environment that could derail agency performance in achieving their mission

Here are some helpful hints as you prepare a SWOT analysis:

  • Be honest and objective. This is not a feel-good analysis. It’s a tool to dispassionately look at your performance. Imagine that you’re looking at your agency from the outside rather than the inside. What have your stakeholders been telling you and others about their perception of your strengths and weaknesses. Include that information in your analysis.
  • If you have objective performance measures, be sure to include your performance on those metrics. If your current agency leadership has been ‘cooking the books’ to make those performance measures look better than they are, I would recommend that you disclose that information (if you have been told your conversation is confidential).
  • If your existing performance measures are weak, subjective, or designed to make your outgoing director or governor look good, make sure to note that in your analysis. If you have ideas about what would be better performance measures it would be a good idea to mention those to the transition team.
  • Include outside assessments in your SWOT analysis. Has the Auditor General’s Office produced reports about your agency? What were the findings? Were they addressed or covered up? For example, if the Auditor General found your predecessor failed to follow up on thousands of serious nursing home complaints… and rather than fix the problem, your predecessor simply reclassified 98% of high-risk complaints as low risk (not requiring prompt follow-up), you should discuss how that happened, who was responsible, and what you’re doing to correct the malfeasance.
  • When possible, include the root cause of your weakness and threats. For example, if you run a public health licensing division and your predecessor(s) or current/past agency director prevented you from hiring staff, wouldn’t update licensing fees to support those staff, or wouldn’t include what you need in the agency budget request, you should identify those decisions as a root cause of your weaknesses.
  • The transition team will also likely be talking with stakeholders about your agency’s weaknesses… and the threats your weaknesses post to them. Anticipate what they will be saying and be candid about those weaknesses. For example, if your Vaccines for Children (VFC) oversight program over-regulated pediatric offices resulting in a more than 50% reduction in VFC providers, you should explain how that weakness/threat happened and what you’re doing (if anything) to rectify the problem.
  • If another part of your agency is posing a threat to your division, make sure to include that in your analysis. For example, if you run the public health division and the operations side of your agency (procurement/accounting) isn’t processing contracts with the county health departments promptly (an agency weakness that poses a threat to the county health departments) be sure to include that weakness and threat in your analysis. Include your honest assessment of what if anything has been done to fix the problem, including who might be responsible.
  • Make sure to identify opportunities that could be created with simple policy changes. For example, if you’ve been deciding to not to apply for federal grants because your current agency director and the outgoing governor won’t allow you to hire people to manage the grant if you get it, include that in your matrix with a suggestion that the incoming administration remove the arbitrary ‘head count’ cap that the Ducey administration has imposed on your agency.
  • Keep the initial SWOT to the A list items in your area of responsibility or your agency. Spreading yourself too thin will muddy the water. Remember, the purpose of this high-level SWOT analysis is to help guide your time with the transition team.
  • As you close out your SWOT in your discussions with the transition team, include strategies that could be used to convert weaknesses into strengths. Maybe you can identify ways to use strengths to overcome threats. Would you be able to use strengths to maximize opportunities if you had better leadership decisions? Are there ways to use strengths to compensate for or minimize weak?

Remember, in some ways a meeting with the incoming administration’s transition team can be seen as a job interview.

The incoming administration will likely be looking for problem-solvers who can objectively assess the performance of their agency and identify strategies to improve performance. They’re unlikely to be impressed with persons who appear to be singing the praises of the outgoing administration/director out of personal loyalty.

For you to speak with candor during your transition team meeting you will need to ensure that your conversation with the team is private and confidential. Do everything you can to create an environment that’s safe and that will allow you to speak candidly.

In short…. just be honest.

It’s a 48 Day Sprint to Inauguration Day: Here’s What We Might Expect During the Transition

Being a candidate for the Office of Governor is a marathon. It takes months of planning and execution, endless public and private events, and countless hours fundraising. It’s a 24/7 commitment with very little (if any) downtime. Your reward, if you win, is a 6-week sprint to prepare to govern.

The Office of Governor is the most powerful and influential in the state. In addition to the enormous executive authority, the governor also oversees more than 38 state agencies and dozens of boards & commissions). With only a few weeks to prepare to take office, having an effective team to help you prepare to take the reins of state government is crucial. Most governor elects prepare by forming a transition team of advisors.

Most governor-elect’s will announce who will be on their ‘transition team’ shortly after the election is called in their favor. They almost always will have a single person who is the “head” of their transition team, but sometimes there’s a fake head of the team and a real one.

  • Ducey quickly named Jon Kyl as the head of his transition team, but everyone knew the real head was Kirk Adams.
  • Governor Brewer named Chuck Coughlin from HighGround as the lead for her transition team. Jay Heiler was the ‘Deputy Director of Transition for Personnel’ and Doug Cole was the ‘Deputy Director of Transition for Operations & Communications’.
  • Napolitano tapped former chiefs of staff for two former governors to lead her transition team: Andrew Hurwitz (chief of staff for Governors Babbitt & Mofford), and Chris Herstam (chief of staff for Governor Symington).

Governor elect’s often name all the members of the transition team when they announce the leads. Team members come with various areas of expertise and sometimes have a stake in who ends up in positions of leadership in state government – but not always. Here are the persons that were on Brewer’s Transition Team. Sometimes governor elects will have a core list of formal transition team members and a more informal list of folks they will tap for advice or input as needed.

On Thursday (November 17) Governor-elect Katie Hobbs named Monica Villalobos, president and CEO of the Arizona Hispanic Chamber of Commerce and Mike Haener, former deputy chief of staff to Governor Janet Napolitano to be the co-leads of her transition team. Additional members of the Hobbs formal transition team or its structure haven’t been announced yet… but transition team members are usually divided into groups that focus on specific areas of the executive branch. Here are some typical examples of working groups:

  • Criminal Justice & Public Safety
  • Natural Resources, Environment & Infrastructure
  • Education
  • Health & Human Services
  • Economic Development
  • Fiscal Policy & Budget
  • General Government

What Does a Transition Team Do?

Transition teams generally have operational goals: 1) Interviewing current administration officials; 2) Making personnel recommendations; and 3) Reviewing agency briefing materials & making recommendations about state government policies & operations.  Health and human services transition team members will usually come with some understanding of the agency’s reputation and that of its leadership.

The personnel & policy recommendations made by the transition team can have a profound (and long-term) impact on state government operations and decision-making.

Reviewing Materials Prepared by Agencies

One of the first things the transition team groups do is ask for the agency’s briefing materials. As they review the quality and content of the briefing documents, they ask themselves: Is this high-quality and professionally prepared? Are the materials objective or self-serving? Do they appear to be prepared at the last minute? How useful is the information?

Meeting with Agency Staff & Stakeholders

The transition team also schedules individual meetings with existing agency directors and their assistants. They usually ask for a 1:1 format so they can get honest answers. For example, if an agency has a weak director who doesn’t know the agency’s subject matter, pays little attention to detail, and/or has difficulty making decisions – the team would like to hear about that from the assistant and deputy directors in an environment where they’re more likely to get honest assessments.

The interviews between the transition team and persons in agency leadership positions are a tightrope walk. If you speak with candor about the weaknesses of your agency director and the sitting governor’s team, you’re risking being dismissed before the inauguration (if there’s a leak). If you’re not honest or withhold your opinion of existing leadership, you risk giving the perception to the transition team that you are part of the problem rather than part of the solution.

Transition team members also often talk to key stakeholder groups that work or are affected by agency decisions and operations. For example, I’d expect members of the upcoming transition team for ADHS to talk with a few of the directors of the county health department to find out what they think of the current director and leadership team – and to get a sense of agency strengths and weaknesses.

Likewise, I’d expect the transition team group to talk with those regulated by the agency’s licensing division and the bureau of emergency medical services. I’d expect them to reach out to the behavioral health community to get a sense of how engaged the director and leadership have been at managing care and regulating the Arizona State Hospital.

Making Personnel & Policy Recommendations

The transition team will be making recommendations to the new governor quickly because of the time constraints involved. They’ll be looking for agency heads that they believe are wholly unqualified for the current position, some that may be OK for now, and some they think are solid performers that they would recommend for retention. There’s always a blend of the three.

As the transition team meetings are happening, agency directors and sometimes Assistant and Deputy Directors are often invited to reapply for their existing position. The transition team will have activated a website where people can apply for positions in the new administration (that website usually goes up in early November).

They’ll also be working their professional and personal contacts to identify persons that might be a good fit for key leadership positions in the agencies.

As the transition continues, agency staff – especially the 38 agency directors – will be paying close attention to the verbal and nonverbal cues they get from the emerging governor’s team. Agency directors can’t be fired by the incoming administration before the inauguration but are often given subliminal signals about whether they’re likely to be retained or not.

See: Social-service agency chief resigns as Ducey takes office

Governor’s Office Staff

Governors usually tell their transition team heads who they’d like to see as their chief of staff. That’s usually one person, but not always. For example, Napolitano informed her transition co-chairs (Hurwitz & Herstam) that she wanted co-chiefs of staff – one for policy (Dennis Burke) & one for operations (Alan Stephens).

The governor elect will announce who their chief of staff and other advisors will be (usually in November). Sometimes, these persons will be members of the transition team or professional contacts who they have. They are often people who the governor-elect has worked with personally or professionally over the years. Some may even come from the website where people are invited to apply for positions with the administration (but that happens rarely in my experience).

As the governor’s office personnel fall into place the transition team usually takes on less importance as the incoming governor will generally begin to also listen to and act on the recommendations of his or her new staff.

The Finish Line

The transition team’s work is fast and furious in November and December but usually wraps up before the inauguration. Members of the budget/finance transition team may continue to work until the new governor sends her proposed budget to the legislature in mid-January.

Epilog

In my experience, transitions don’t end at the inauguration. They go on for about 6 months. As the governor and her staff on the 8th and 9th floor learn more about the persons at the state agencies, they begin to solidify their opinions about where they want to make more policy or personnel changes.

As issues come up, they ask themselves:  Does this person seem competent? Can I count on this person in an emergency? Is this agency working well for the public? What kind of feedback am I getting from stakeholders about this person/agency? Does this person share my ideology? How loyal does this person seem? Governors place different weights on those criteria.

For example, Governor Brewer was most interested in competence, operational integrity, and service to the public. Governor Ducey was more concerned with optics, personal loyalty, and assurances that the agency director will subjugate their opinions to those of the governor. I expect governor-elect Hobbs to be most interested in competence, operational integrity, and service to the public.

A State Government Transition Team Will Be in Place by This Time Next Week: Here’s How It Usually Works

Within a few days we’ll probably know who the next governor will be. Whether it’s Hobbs or Lake – they’ll just have a few weeks to get prepared to accept the responsibility of being governor (the inauguration is Monday, January 2, 2023).

Governing is different from campaigning. Governing means taking responsibility for the actions of the state agencies, boards, and commissions (there are 38 state agencies and dozens of boards & commissions).

While you might not hear anything about getting prepared to govern on the campaign trail, most candidates have an action plan in case they win. If one starts thinking about the transition after the election, they’re putting themselves at a disadvantage governance-wise. Preparing to take office usually starts with forming a transition team.

Most governor-elect’s will announce who’s on their ‘transition team’ shortly after the election is called in their favor. They almost always will have a single person who is the “head” of their transition team, but sometimes there’s a fake head of the team and a real one.

  • Ducey quickly named Jon Kyl as the head of his transition team, but everyone knew the real head was Kirk Adams.
  • Governor Brewer named Chuck Coughlin from HighGround as the lead for her transition team. Jay Heiler was the ‘Deputy Director of Transition for Personnel’ and Doug Cole was the ‘Deputy Director of Transition for Operations & Communications’.
  • Napolitano tapped former chiefs of staff for two former governors to lead her transition team: Andrew Hurwitz (chief of staff for Governors Babbitt & Mofford), and Chris Herstam (chief of staff for Governor Symington).

Governor elect’s often name all the members of the transition team when they announce the leads. Team members come with various areas of expertise and sometimes have a stake in who ends up in positions of leadership in state government – but not always. Here are the persons that were on Brewer’s Transition Team.

Governor elect’s also frequently set a “transition tone” by showing greater interest in certain issues & agencies. They sometimes also have a preconceived view of an agency (often negative). For example, in a half-hour interview with Dennis Welch this week Kari Lake indicated she will “… clean house at the Department of Health Services and fill it with doctors who understand science.”

Transition team members are usually divided into groups that focus on specific areas of the executive branch. Here are some typical examples of working groups:

  • Criminal Justice & Public Safety
  • Natural Resources, Environment & Infrastructure
  • Education
  • Health & Human Services
  • Economic Development
  • Fiscal Policy & Budget
  • General Government

What Does a Transition Team Do?

Transition teams generally have operational goals: 1) Interviewing current administration officials; 2) Making personnel recommendations; and 3) Reviewing agency briefing materials & making recommendations about state government policies & operations.  Health and human services transition team members will usually come with some understanding of the agency’s reputation and that of its leadership.

The personnel & policy recommendations made by the transition team can have a profound (and long-term) impact on state government operations and decision-making.

Reviewing Materials Prepared by Agencies

One of the first things the transition team groups do is ask for the agency’s briefing materials. As they review the quality and content of the briefing documents, they ask themselves: Is this high-quality and professionally prepared? Are the materials objective or self-serving? Do they appear to be prepared at the last minute? How useful is the information?

Meeting with Agency Staff & Stakeholders

The transition team also schedules individual meetings with existing agency directors and their assistants. They usually ask for a 1:1 format so they can get honest answers. For example, if an agency has a weak director who doesn’t know the agency’s subject matter, pays little attention to detail, and/or has difficulty making decisions – the team would like to hear about that from the assistant and deputy directors in an environment where they’re more likely to get honest assessments.

The interviews between the transition team and persons in agency leadership positions are a tightrope walk. If you speak with candor about the weaknesses of your agency director and the sitting governor’s team, you’re risking being dismissed before the inauguration (if there’s a leak). If you’re not honest or withhold your opinion of existing leadership, you risk giving the perception to the transition team that you are part of the problem rather than part of the solution.

Transition team members also often talk to key stakeholder groups that work or are affected by agency decisions and operations. For example, I’d expect members of the upcoming transition team for ADHS to talk with a few of the directors of the county health department to find out what they think of the current director and leadership team – and to get a sense of agency strengths and weaknesses.

Likewise, I’d expect the transition team group to talk with those regulated by the agency’s licensing division and the bureau of emergency medical services. I’d expect them to reach out to the behavioral health community to get a sense of how engaged the director and leadership have been at managing care and regulating the Arizona State Hospital.

Making Personnel & Policy Recommendations

The transition team will be making recommendations to the new governor quickly because of the time constraints involved. They’ll be looking for agency heads that they believe are wholly unqualified for the current position, some that may be OK for now, and some they think are solid performers that they would recommend for retention. There’s always a blend of the three.

As the transition team meetings are happening, agency directors and sometimes Assistant and Deputy Directors will be invited to reapply for their existing position. The transition team will have activated a website where people can apply for positions in the new administration (that website usually goes up in early November).

They’ll also be working their professional and personal contacts to identify persons that might be a good fit for key leadership positions in the agencies.

As the transition continues, agency staff – especially the 38 agency directors – will be paying close attention to the verbal and nonverbal cues they get from the emerging governor’s team. Agency directors can’t be fired by the incoming administration before the inauguration but are often given subliminal signals about whether they’re likely to be retained or not.

See: Social-service agency chief resigns as Ducey takes office

Governor’s Office Staff

Governors usually tell their transition team heads who they’d like to see as their chief of staff. That’s usually one person, but not always. For example, Napolitano informed her transition co-chairs (Hurwitz & Herstam) that she wanted co-chiefs of staff – one for policy (Dennis Burke) & one for operations (Alan Stephens).

The governor elect will announce who their chief of staff and other advisors will be (usually in November). Sometimes, these persons will be members of the transition team or professional contacts who they have. They are often people who the governor-elect has worked with personally or professionally over the years. Some may even come from the website where people are invited to apply for positions with the administration (but that happens rarely in my experience).

As the governor’s office personnel fall into place the transition team takes on less importance as the incoming governor will generally begin to also listen to and act on the recommendations of his or her new staff.

The Finish Line

The transition team’s work is fast and furious in November and December but usually wraps up before the inauguration. Members of the budget/finance transition team may continue to work until the new governor sends her proposed budget to the legislature in mid-January.

Epilog

In my experience, transitions don’t end at the inauguration. They go on for about 6 months. As the governor and her staff on the 8th and 9th floor learn more about the persons at the state agencies, they begin to solidify their opinions about where they want to make more policy or personnel changes.

As issues come up, they ask themselves:  Does this person seem competent? Can I count on this person in an emergency? Is this agency working well for the public? What kind of feedback am I getting from stakeholders about this person/agency? Does this person share my ideology? How loyal does this person seem? Governors place different weights on those criteria.

For example, Governor Brewer was most interested in competence, operational integrity, and service to the public. Governor Ducey was more concerned with optics, personal loyalty, and assurances that the agency director will subjugate their opinions to those of the governor.

By next week’s policy update we will know who the next governor will be – and perhaps I’ll be able to shed light on what the next couple of months will bring.

ADHS Declined to Investigate Nursing Home Where Elderly Resident was Sexually Assaulted

ADHS spokesperson Steve Elliott tells 12News the agency’s policy has since changed. Now, a serious crime triggers a site survey

Link: ADHS didn’t investigate after elderly resident sexually assaulted

Author: 12News’  Bianca Buono

Published: 6:15 PM MST November 4, 2022

Updated: 8:04 PM MST November 4, 2022

FLAGSTAFF, Ariz. — Arizona’s Department of Health Services declined to investigate a Flagstaff nursing home after learning that an employee had sexually assaulted an elderly resident with memory issues.

The sexual assault happened at The Peaks in Flagstaff in January of 2021. Records show ADHS had visited The Peaks for a survey in December of 2020 and did not return until August of 2022.

ADHS spokesperson Steve Elliott told 12News in an email that the agency could have conducted an on-site survey “to examine how a facility followed other state rules and regulations” but they did not.

The employee-turned-suspect, Jonathan Chesley, was found guilty of sexual assault in October and is scheduled to be sentenced in December. He was working at The Peaks as a med tech.

RELATED: Flagstaff caregiver convicted of sexual assault

Former ADHS director critical of lack of ADHS action

“I mean, it’s outrageous,” said Will Humble.

Humble is a former ADHS director and current executive director for the Arizona Public Health Association.

Humble said he cannot comprehend the lack of state action after such an egregious crime.

“It’s outrageous that a state agency wouldn’t follow up on a verified report of a sexual assault by a staff member on a vulnerable patient in a nursing home. And they wouldn’t even show up for 18 months,” Humble said.

Chesley’s coworker walked in on him apparently sexually assaulting the elderly woman, according to a Flagstaff police report.

Chesley had previously been fired from another nursing home in the area. Records show he had told his two colleagues to take their breaks at the same time, a violation of policy, which meant he was left alone in the memory care unit.

The victim’s family filed a lawsuit against the facility alleging bad hiring and training practices and alleged the facility was negligent. Court documents show the facility settled with the family.

Humble believes they should have added ADHS to the lawsuit, too.

“This is a high-risk situation that suggests that there could be a systemic problem either with governance, hiring, staffing, training, oversight supervision, that led to a situation that would allow this to happen,” Humble said. “The only way you can tell whether that’s the case is to go out and do a field investigation.”

That investigation did not happen.

“There is no discretion. There is no judgment call. This is a high-risk situation. It’s a high-risk complaint,” Humble said.

Earlier this year, the auditor general released a bombshell report revealing a widespread problem at ADHS. After looking at records from July 2019 to April 2021, the auditor general said ADHS did not investigate complaints quickly enough, or sometimes at all, in nursing homes. These included reports of abuse and neglect.

RELATED: ADHS failing to investigate complaints at nursing homes: Auditor General report

“It’s super sad and the people of Arizona deserve better,” Humble said.

Elliott told 12 News ADHS has since changed its process. Now, whenever a serious crime is reported at any facility licensed by ADHS, the agency will respond by conducting an on-site survey “looking for any gaps in following state rules and regulations.”

Editorial Note: With the departure of Cara Christ and Colby Bower to Blue Cross Blue Shield of Arizona, ADHS has much better leadership in their licensing division (Tom Salow is leading that team now). The licensing division has suffered for many years with poor leadership, but that has now finally changed.

Let’s hope that the incoming governor recognizes that the current leadership is not responsible for the disturbing auditor general’s reports that documented a willful effort to cover up, rather than fix major problems at the department’s licensing division.

See: Auditor General’s Office Produces Scathing Review of ADHS’ Nursing Home Complaint Investigations During the Director Christ Era

Yesterday’s Assaults at the Arizona State Hospital Highlight the Need for ASH/ADHS Governance Reform: A Primer

On Monday, November 1, 2022, two patients at the Arizona State Hospital’s Forensic Unit briefly held 3 ADHS/ASH staffers hostage. They were also assaulted. The forensic patients who attacked staff have been arrested and removed from the hospital. Thankfully, the ADHS staffers do not appear to have been seriously physically injured.

See: Recent Attacks Spark New Calls for More Oversight for Arizona State Hospital & 2 Patients Arrested After Arizona State Hospital Workers Held Hostage

Spokespersons from ADHS claim that low staffing levels have ‘nothing to do with the situation’ despite the fact that ASH has more than 100 vacant positions, nearly 15% of the workforce. Also, the agency spokesperson (Steve Elliott) said staffing had nothing to do with the assaults way before the agency could have conducted a root cause analysis.

Staffing shortages may or may not be a direct or indirect cause of yesterday’s assaults, but a longstanding governance conflict – the fact that the Arizona Department of Health Services both runs and ‘regulates’ the Arizona State Hospital almost certainly has played a role.

In this blog we explain the background about why it’s bad for a state agency to regulate itself and describe a simple and evidence-based solution that would have corrected the governance conflict. That bill was killed by Governor Ducey’s staff during the 2022 legislative session.

The Bill

AzPHA had been a big supporter of SB1716 Arizona State Hospital; Governing Board. The bill (by Senator Gowan) would have changed the governing structure for the Arizona State Hospital (ASH) from one in which the Arizona Department of Health Services both runs and ‘regulates’ ASH to a model in which ASH has independent oversight, building much better checks and balances into the system of governance.

SB1716 sailed through the State Senate with nearly unanimous support and was transferred to the AZ House of Representatives. There, it received a 9-0 pass recommendation by the House Health Committee. The bill then languished in the House Rules committee. Reliable sources tell me that Ducey governor’s office staff asked Representative Grantham to hold the bill in Rules, which he did…  killing this important bill.

SB1716 would have set up a new Governing Board which would oversee operations at ASH. The Superintendent would report directly to the Governing Board rather than the ADHS Director. The Arizona Department of Health Services would then be able to regulate the Arizona State Hospital free from conflicts of interest.

Here’s an article by Mary Jo Pitzl at the Arizona Republic with more detail.

Why is that important? It’s simple. Right now, there is a huge conflict of interest because the ADHS Director is responsible for both running and regulating ASH. It’s never a good governance model to have an entity regulate itself! It’s very simple for the ADHS Director to send an implicit (or even explicit) message to her or his team to go easy on ASH to keep things quiet. Indeed, recent complaint investigations of serious allegations often find ‘no deficiencies’. That’s just hard to believe, especially when the fox is watching the henhouse.

For context read this article by Amy Silverman: Patient deaths at Arizona State Hospital raise questions about staffing levels, lack of oversight

ADHS Leadership has in the past suggested that there is independent oversight of ASH via the Center for Medicare and Medicaid Services & the Joint Commission. Their statements have been misleading. To clear things up, we prepared this review of how the Arizona State Hospital is actually ‘regulated’ under the current model. We close with a review of why this bill was so important.

Overview

There are 3 components to the Arizona State Hospital (ASH)…  the Civil Hospital, Forensic Hospital, and the Arizona Community Protection and Treatment Center (ACPTC). The regulatory oversight differs for the 3 components that make up ASH.

Civil Hospital

The ASH Civil Hospital provides treatment and care for persons that are court ordered to the facility for psychiatric care.  The Civil Hospital at ASH is run and regulated by the Arizona Department of Health Services (ADHS). ADHS’ Licensing Division is responsible for regulating the Civil Hospital which the ASH Superintendent is responsible for its operation.

State Licensure

State law allows healthcare institutions like ASH’ Civil Hospital to enjoy a Deemed Status license from the ADHS. That means that the Civil Hospital can hire an accrediting body to accredit the Civil Hospital. Once accredited, the Civil Hospital turns in the accrediting report to the ADHS Licensing division, and the ASH Civil Hospital receives a License from the ADHS – even though the ADHS doesn’t do an inspection of the facility before issuing the license.

The ADHS pays The Joint Commission (TJC) to accredit the Civil Hospital. ASH Civil started hiring TJC to do that work when I was Director. I think we paid TJC something like $10K for that service. Here’s a link to the deemed status licensing information about the Civil Hospital: Licensing Statement of Deficiencies (azdhs.gov).  ADHS accepts the accreditation in lieu of an inspection and issues the state license to operate on that basis.

While the ADHS doesn’t do any annual inspections of the Civil Unit (because of its ‘Deemed Status’), the ADHS Licensing division can send out surveyors to investigate complaints about the care at the Civil Hospital when they receive them. If the complaint is substantiated, the ADHS Licensing Division can require corrective action and has some enforcement authority like issuing civil money penalties or placing the facility on a provisional license or even seeking revocation.

You can see that ADHS ‘complaint investigations’ seldom substantiate the complaints they receive and seldom find deficiencies (with a few exceptions). Here’s the recent compliance record: Licensing Services Facilities Report (azdhs.gov)

CMS Certification

Because Medicare and Medicaid (AHCCCS in Arizona) pay for some of the services at the ASH Civil Hospital, CMS requires that the ASH Civil Hospital be Certified to their certification standards. However, CMS doesn’t do their own certifications. They contract with the ADHS Licensing staff on the 4th floor of the ADHS building to conduct the certification inspections.

ADHS licensing staff go out and check at the ADHS ASH Civil Units to see if they’re adhering to CMS’ certification standards (which are a little different from the actual ADHS healthcare Institution regulations). ADHS Licensure then sends their report to CMS Region IX in San Francisco and the report is blocked, copied, and pasted and is sent back on CMS letterhead.

Civil Unit Summary

ADHS both runs and regulates the ASH Civil Hospital. ADHS leadership often suggest that there are checks and balances in the regulatory system to send the message that the monitoring of care is rigorous. The fact is that CMS Certification is not an independent review of care at the Civil Hospital because the work is conducted by ADHS Licensing staff.

While it’s true that The Joint Commission accreditation is separate from ADHS, the ADHS voluntarily pays TJC for the accreditation surveys and TJC views ADHS as a customer/client. TJC is not a regulatory body, and they have no enforcement authority. TJC Accreditation inspections that document deficiencies can sometimes jeopardize their contract with their customer, which has a chilling effect on documenting deficiencies.

Forensic Hospital

The ASH’ Forensic Hospital provides care for patients that are determined by the courts to be “Guilty Except Insane” or “Not Guilty by Reason of Insanity”.  The Forensic Hospital is also both run and ‘regulated’ by the ADHS Licensing Division.

State law allows healthcare institutions like ASH’ Forensic Hospital to enjoy a Deemed Status license from the ADHS. That means that the Forensic Hospital can also hire an accrediting body to accredit the Forensic Hospital. Once accredited, the Forensic Hospital turns in the accrediting report to the ADHS Licensing division and receives a License from the ADHS – even though the ADHS doesn’t do an actual inspection of the facility. The ADHS also pays The Joint Commission (TJC) to accredit the Forensic Hospital.

When the ADHS Licensing division receives complaints about care at the Forensic Hospital they can send out surveyors to investigate those complaints. If the complaint is substantiated, the ADHS Licensing Division can require corrective action and has some enforcement authority like issuing civil money penalties or placing the facility on a provisional license or even seeking revocation.

You can see that ADHS ‘complaint investigations’ seldom substantiate the complaints and seldom do they find deficiencies (with some exceptions). Here’s the recent compliance record: Licensing Services Facilities Report (azdhs.gov)

Because CMS doesn’t pay for services at the Forensic Hospital there’s no need for CMS Certification of ASH’ Forensic Hospital.

Arizona Community Protection and Treatment Center

The Arizona Community Protection and Treatment Center (ACPTC) provides residential and care services for people that are civilly committed by the courts to the facility as a ‘Sexually Violent Person’. The ACPTC is licensed by the ADHS Licensure Division. They are not accredited by The Joint Commission nor are they accredited by CMS.

Conclusion

The current governance structure for operating and regulating the Arizona State Hospital is fundamentally flawed because the ADHS both runs and regulates the facilities. The lack of independent regulation and oversight results in poor accountability and can lead to unchecked substandard care when ADHS leadership soft-pedals regulatory oversight to give the appearance that the facilities are providing care that meets standards.

SB1716 was a needed reform of the governance structure that would have move operational responsibility for operating ASH to an independent Governing Board. ADHS would continue to regulate the facilities but would be relieved of the conflict of interest that comes with running and regulating the same facility.

Sadly, Governor Ducey’s team killed the bill in House Rules this year…  but we are confident that this commonsense intervention will eventually prevail. In the meantime, there will continue to be a lack of checks and balances – making assaults like yesterday more likely.

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The ‘Vaccines for Children’ Program Is Critical to Maintaining Childhood Vaccination Rates… but Provider Participation Has Plummeted During the Ducey Administration

The Vaccines for Children Program makes sure kids whose parents can’t afford vaccines can still get them. Funding for VFC comes via CMS to the CDC, who buys vaccines at a discount and distributes them to states. States then distribute them to physicians’ offices & clinics that take part in the VFC program. The Arizona Department of Health Services manages the VFC program in our state.

The VFC program covers vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) for these 16 diseases

Doctor’s offices and clinics are required to be enrolled as a VFC provider by ADHS in order to take part in the Medicaid program…  so, the number of providers enrolled in VFC has a direct impact on the adequacy of a state’s care network for kids enrolled in Medicaid (AHCCCS).

Arizona’s VFC Provider Network Decreased Dramatically During the Ducey Administration

Arizona has a big problem that that you may not have heard much about: Providers have been dropping out of the VFC program in droves large part because of ADHS’ over-regulation of the VFC program (although industry consolidation has also played a role).

Arizona lost 50% of its VFC providers during the Ducey administration, going from 1,200 providers in 2015 to only 600 today

Why the decline? If you talk to providers who left VFC over the last few years, many will tell you they quit because of the administrative hassles that have been imposed on them by the state (ADHS not AHCCCS). At the top of the list of grievances is ADHS’ punitive practice of financially punishing providers with wastage rates over 5%.

Even though pediatric providers lose money by participating in the VFC program, the ADHS has been fining them for replacement doses if they had a 5% or higher wastage rate (see this letter to AZAAP members regarding the ADHS policy)

See Arizona’s Vaccines for Children (VFC) Program Requirements

How Does Arizona’s VFC Enrollment Compare to the Rest of the US?

Not good. Arizona has 6 VFC providers per 10,000 Medicaid eligible kids, while the national average is 24 providers per 10,000 Medicaid kids…  meaning Arizona only has a quarter of the number of VFC providers per Medicaid kid compared with the national average. Many people believe that the declining immunization rates among AZ kids are in part due to a thinning network of VFC providers in Arizona.

Childhood Vaccination Rates Continue to Drop In the 2021-2022 School Year

Hopefully there will be new leadership coming to the ADHS in a few months – and perhaps that person will reverse the erosion in VFC participation that occurred during the Ducey administration. Maybe she or he will even alter their policies to encourage (rather than discourage) participation in VFC (and by extension, improve the pediatric Medicaid network).

The next ADHS director should start by engaging stakeholders like the Arizona Academy of Pediatrics, Arizona Academy of Family Physicians, the Arizona Partnership for Immunizations & AHCCCS and do a root-cause analysis of the decline in participation and then create and implement a plan to reengage providers in taking part in VFC.

The group should also decide whether the ADHS is actually the best place to manage the VFC program or whether it belongs over at AHCCCS.

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