Will Humble Firearm Safety, Public Health, Wills Blog

AzPHA’s Firearm Violence Report Featured in “The Nation’s Health”

AzPHA’s landmark report of firearm violence epidemiology and intervention evidence review is featured in the June edition of the American Public Health Association’s monthly newspaper The Nations Health

The article discusses how the AzPHA Board of Directors identified firearm violence as a top priority and how our affiliate followed through by publishing our comprehensive report.

The piece does a nice job answering ‘why’ we felt compelled to write the report and our hope that the work will translate into policy action by implementing some evidence-based foundational laws that have been proven to reduce firearm injury and mortality.

Any good policy intervention starts with surveillance and an evidence review, and we decided to do that…   to fill that gap. Any good Affiliate should think of themselves as a conduit for policy change and face the kinds of issues where there is resistance at the state level in terms of the governor.

Also from the article: ‘Making the report a reality was no easy task. The public health impact of firearm violence was not a priority for state agencies during the administration of former Arizona Governor Doug Ducey. A lack of buy in at the state level kept the health department from leading on gun violence prevention, but as a nonprofit organization, AZPHA is able to advocate for causes that might challenge the direction taken by state agencies.’

See the full article in The Nation’s Health: June 2023

Will Humble Uncategorized

Legislative Update: Second ‘Spring Break’

The House & Senate worked one day last week (Monday) and then promptly recessed until Monday, June 12.

The Legislature also took final votes on many of the remaining bills still in process, but most of them were hyper-partisan and can expect to meet with Governor Hobbs’ well-used veto stamp in the coming days. AZPHA is urging the governor to veto SB1234 – which would eliminate photo enforcement of traffic laws, although because that bill was modified in the House it is going back to the Senate again before it would hit Hobbs’ desk.

See: Do Red Light Cameras Save Lives? The Evidence Says YES

SB1710, which would extract the Arizona State Hospital from ADHS and report to a 5-member Board starting January 1, 2025 remains in limbo in the House, where it needs to go through Committee of the Whole and then a final floor vote. Whether it will make it through the process remains unclear.

Governor Hobbs vetoed one of the worst bills of the session last week, HB2545. Veto Letter HB2545. That bill would have limited the ability of the Governor to declare a public health emergency to 7 days. Extending the emergency would require 2/3 vote of the legislature. Extensions could last just 1 week, and the legislature would need to extend them every week with a 2/3 vote.

A rumor is circulating suggesting that the Legislature will remain perpetually in session, something that has never happened before. I think that’s hogwash because most bills don’t become effective until 90 days after the end of session…  and majority members are anxious to see bills that Hobbs did sign go into effect.

Will Humble Behavioral Health, Medicaid, Wills Blog

Stunning Medicaid Fraud Uncovered in AZ

No doubt you’ve heard about the massive fraud and human trafficking scheme that went on for the last several years in Arizona. Governor Hobbs & Attorney General Mayes led a press conference last week where they laid out the big picture of what they discovered had happened during the Ducey Administration.

Operators or associates of the sham healthcare centers picked up people who are unhoused, low-income, alone or intoxicated, and transported them to residential centers after promising to provide food, housing, and access to care. Perpetrators were mostly targeting Native Americans on reservations & in urban areas. 

The bottom line is that operators of fraudulent sober living homes and residential behavioral health facilities have for years been raking in taxpayer dollars from AHCCCS by recruiting Native Americans to enter the facilities and billing for treatment that was never provided. 

The fraud was made possible by a fee-for-service reimbursement mechanism inside AHCCCS’ American Indian Health Plan that allows providers to bill for services they say they provided rather than the more mainstream capitated system the rest of AHCCCS uses.

AHCCCS failed to either recognize that the fraud had been going on for years- or knew about the fraud but took little coordinated action. At the press conference Mayes said attorneys in the AG’s office during the Brnovich era had uncovered cases of abuse and raised concerns with AHCCCS but that Brnovich and Ducey didn’t uncover the full extent of the problems. 

AHCCCS payouts for outpatient behavioral health services increased more than 10-fold from 2019 to 2022 – going from $53M in FY 2019 to $668M in 2022. How in the world claims could expand 1,000% in 3 years and not be flagged for scrutiny is dumbfounding – especially for an agency that has cost-containment literally in its name.

Perhaps Attorney General Mayes said it best: “I don’t think it is too much to say that this is one of the biggest scandals in the history of the state of Arizona… our office estimates that it is in the hundreds of millions of dollars – it could go higher than that”.  

As an initial intervention, AHCCCS has suspended future payments to Medicaid 100 behavioral health providers because of the fraudulent billing activities. The Arizona Attorney General’s Healthcare Fraud and Abuse Section, the Federal Bureau of Investigation, the US Department of Health and Human Services, the US Attorney’s Office, and the Internal Revenue Service are also looking into this widespread and tragic disaster.

AHCCCS (now under new management) says the suspensions are the first step and that that this action is just the beginning of multi-agency investigations. They also announced some first step actions to prevent further fraud and trafficking like:

  • Reviewing existing claims and setting specific rates for current billing that pay a percentage of the total billed amount instead of a standard rate;
  • Creating a trend report of all providers registering for the at-risk provider types and closely monitoring any billing anomalies;
  • Creating system reporting to flag concerning claims (volume, services per day, services for minors) for review prior to payment;
  • Setting billing thresholds to deny claims for multiple services that should not be billed on the same day, and more; and 
  • Moving three behavioral health provider types to the high-risk category for new applicants and revalidating providers.

An ongoing and regularly updated list of registered providers subject to payment suspension or termination is posted on the AHCCCS Office of Inspector General Provider Suspensions web page. See more information in the Provider Payment Suspensions Fact Sheet.

As providers are terminated, there will no doubt be persons in both licensed and unlicensed sober living homes at risk of abandonment. AHCCCS is working to ensure persons who were receiving services but may no longer be getting them have a way to get back to where they want to be or into an alternative legitimate care setting. This will be a lot of work.

What is ADHS’ Role?

ADHS licenses sober living homes, behavioral health residential facilities, and outpatient clinics. They are responsible for ensuring that licensed facilities comply with ADHS licensing rules – which focus on health and safety.

ADHS doesn’t pay for services provided and isn’t involved in the billing, but they do have statutory authority to ensure patients are treated properly. It remains unclear what the ADHS licensing division discovered or did during the 2019-2022 time period when this massive fraud and human trafficking scheme flourished.

ADHS posted a couple of useful blogs last week that cover their responsibilities to license and regulate sober living homes and residential behavioral health facilities. Rather than paraphrase…  it’s best to post a link so here goes:  How we license facilities that provide substance abuse recovery resources – ADHS Blog

Will Humble Emergency Management, Public Health, State Legislature, Wills Blog

State Budget in the Books w/ Some Public Health Gains: A Summary

The Legislature passed and the governor signed what turned out to be a bipartisan budget last week. The $17.8B budget was negotiated by House Speaker Toma, Senate President Petersen & Governor Hobbs.

Many members in both chambers expressed frustration that there hadn’t been a more collaborative process, but ultimately voted in support. In general, all of the Republicans voted for the budget as did 9 Democratic senators and 16 D representatives.

You can find a line-by-line analysis prepared by the Joint Legislative Budget Committee here and you can see the bill line items in the feed bill.

Both chambers are meeting today for floor calendar action (COW and 3rd Read). Word on the street is both chambers will break until Monday, May 22 after today.

One important thing on the calendar today are in Senate COW is HCR2039 governor; state of emergency, which would dismantle the Recovery phase of emergencies in Arizona. Calendars

Last-minute questions by Senator Bennett in a (R) caucus meeting highlighted the damage the measure would cause to emergency management if the voters would have approved it. Let’s hope it fails in what’s likely to be a final 3rd read vote Monday. If it passes, Governor is unable to veto it and it’ll be on the November 2024 ballot.

Ballot Referral Could Dismantle Arizona’s Emergency Management System

SB1234 is up for a final vote in the House this afternoon. That one would prohibit cities or counties from using photo enforcement technology to enforce speeding or red light running.  

Do Red Light Cameras Save Lives? The Evidence Says YES

Here’s a breakdown on what the final budget package looked like from a public health perspective.

Housing Trust Fund Gets Big Cash Infusion

The biggest public health benefit in the budget is an unprecedented infusion of $150M into the state Housing Trust Fund. That fund provides the AZ Department of Housing with its most flexible source of money and includes healthy match for federal housing funds. It can be used for affordable housing development, housing aid programs and money for homeless shelters, transitional housing, eviction prevention, rapid rehousing, and other innovative activities. The Dept of Housing will set those priorities in the coming months.

Kids Care Extended to 225% of FPL

The second biggest, good thing for public health in the budget was a more generous eligibility level for families to take part in KidsCare. The budget bill relaxed the eligibility level from 200% of the federal to 225%.  This is expected to expand access to health insurance for approximately 9,500 kids in FY24, and 12,000 in FY25.

No Medicaid Adult Dental Benefit

The biggest public health disappointment was the failure to include a preventive oral health benefit for adult AHCCCS members. A reasonable and inexpensive proposal to begin covering a limited dental benefit was not made a priority and wasn’t included in the negotiated agreement.

Adult Medicaid members will still be eligible for a very limited $1K/year emergency dental benefit – but nothing else. That’s about enough to cover a couple of pulled teeth, but that’s about it.

Collaborative Care Initiative

There are a couple small scale things in the budget that are worth mentioning including a $1M line item that ADHS is getting to set up ‘collaborative care model’ templates to encourage formal collaborative arrangements among primary care physicians, care managers and a psychiatric consultant.

ADHS is supposed to ask for proposals from and enter into grant agreements with collaborative care technical assistance center applicants to supply technical aid to primary care physicians on providing behavioral health integration services through the collaborative care model.

Looks to me like this is set up to benefit a specific entity- but I’m not sure who.

Dementia & Alzheimer’s Disease

ADHS is also getting about $1.5M to coordinate a plan to deal with Alzheimer’s disease and dementia. They’re supposed to coordinate ‘support of policies and programs’ in the executive branch that relate to Alzheimer’s disease & dementia with the money.

The work is supposed to include a State Plan that ‘coordinates outreach programs and services between state agencies, local public health departments, tribal nations, educational institutions, and community groups to foster public awareness and education about Alzheimer’s disease and related forms of dementia’.

They’re also supposed to facilitate the ‘coordination of services and activities among the area agencies on aging, service providers, advocacy groups, legal services, emergency personnel, law enforcement, local public health departments, tribal nations and state colleges and universities’. Another responsibility includes incorporating early detection and risk strategies into existing public health programs.

ADHS is only getting $964K for all that work, which doesn’t seem very much compared to what they’re expected to do.

They’re also getting another $500K for an “education campaign to increase awareness of Alzheimer’s disease in rural and underserved urban areas”.  The language in the law is super specific and it’s pretty clear that this is an earmark for the Alzheimer’s Association.

Psilocybin (Magic Mushroom) Research Council

The budget also created a Psilocybin Research and Advisory Council that’s supposed to oversee competitive research grants (using the $5M appropriated) for ‘whole mushroom psilocybin clinical trials’ to evaluate the effects of whole mushroom psilocybin on treating a host of conditions.

Interestingly, the law didn’t give the money to the Arizona Biomedical Review Centre as would have been logical. Not sure why a separate entity was set up instead.

Budget Line-Item Breakdowns

Department of Health Services

  • Arizona State Hospital (ASH) Contracted Services $1,100,000
  • ASH Contracted Services One-time $6,000,000
  • ASH Video Security One Time $3,500,000
  • Alzheimer’s Research Ongoing $500,000
  • Dementia Services and Alzheimer’s State Plan non-lapsing through FY 2026 $964,100
  • Dementia Awareness GF One-time; non-lapsing $500,000
  • Psilocybin Research GF One-time $5,000,000
  • Collaborative Care Uptake Fund GF Onetime $1,000,000
  • Health Crisis Review and Wraparound Services GF One-time $5,000,000

AHCCCS

  • Arizona Health Care Cost Containment System KidsCare Expansion GF Ongoing; from 200% to 225% of the Federal Poverty Level $5,000,000
  • Critical Access Hospitals GF One-time $4,200,000
  • On-Call OBGYN Services GF One-time; non-lapsing $7,500,000
  • KidsCare Expansion OF Children’s Health Insurance Program Fund; ongoing $16,620,800
  •  

ADES

  • Adult Protective Services Backfill GF One-time $9,100,000
  • Produce Incentive Program GF One-time; non-lapsing; “Double Up Food Bucks” $5,462,600
Will Humble Wills Blog

MMWR: 2022 Mortality Data for the U.S.

Provisional Mortality Data — United States, 2022 | MMWR (cdc.gov)

Overall death rates and COVID-19–associated death rates decreased from 2021 to 2022 for most demographic groups compared with 2020, with the exception of certain age groups.

COVID-19–associated death rates increased for all persons aged <15 years. Although the overall and COVID-19–associated death rates decreased for persons aged ≥85 years from 2021 to 2022, rates remained higher for this group compared with all other age groups.

AzPHA member Allan Williams, Ph.D. ran the 2022 CDC Wonder data for AZ (below).

Will Humble Medicaid, Public Health Law, Wills Blog

The Federal COVID-19 Public Health Emergency Ends Thursday: What Will Change? 

The biggest thing that most folks will notice is that payment for COVID testing, treatment and vaccination will start running through people’s regular health plan rather than being paid for separately by the federal government.

Other emergency provisions expire too. For example, vaccination requirements, waivers for the Emergency Medical Treatment and Active Labor Act, enhanced discharge planning & nursing care plans, certain critical access hospital requirements, and some kinds of hospital quality & performance improvement programs will end. You can download an explainer for those things on the Center for Medicare and Medicaid Services website: Guidance for the Expiration of the COVID-19 Public Health Emergency.

From a big picture point of view, COVID-19 will no longer be treated differently… it’ll be treated like any other disease or illness.

Requirements for remaining on Medicaid (AHCCCS) will change a bit too. The COVID-19 public health emergency gave generous incentives to state Medicaid programs if they agreed to not disenroll anybody during the emergency declaration. That disenrollment suspension has expired & AHCCCS has begun determining whether their members still qualify.

AHCCCS thinks about 600,000 of their 2.5 million members may lose eligibility once their year-long redetermination process is finished… and 1/2 of those could be for failing to respond to requests from AHCCCS for information to determine eligibility.

See: AHCCCS Doing Full Court Press to Prepare for Member Redeterminations

The Kaiser Family Foundation put together that summarizes the things that will end or change on Thursday including Medicaid match rates, requirements for private health insurance, and other countermeasures like the numerous Emergency Use Authorizations for COVID-19 tests, and treatments like antiviral agents, monoclonal antibodies, and vaccines. 

Here are some bullets summarizing the changes that will happen:

The end of the federal public health emergency also removes the legal foundation that the U.S. Department of Homeland Security has been using as grounds to immediately turn away and expel people seeking asylum in the U.S. (known as ‘Title 42’).

After Thursday, Customs and Border Protection and the Border Patrol (part of CBP) will no longer be able to immediately expel asylees using Title 42 authority. Many asylees have been waiting in Mexico for the opportunity to request asylum once Title 42 ends…  and we’ll begin to see next week whether the system and communities are able to responsibly manage the situation.

Will Humble Vaccination, Wills Blog

New RSV Vaccine Approved for Seniors

FDA licensed the first-ever vaccine for RSV last week. Vaccines for RSV have been researched for at least 20 years. The is called Arexvy (GSK). The vaccine is licensed for adults ages 60 and older.  A similar vaccine from Pfizer is expected to be approved in June (same demographic).

CDC still needs to recommend the vaccine before it will be available. The next Advisory Committee on Immunization Practices meeting is on June 21/22.

A vaccine to protect infants is expected to gain FDA approval later this year. That one is developed by Pfizer. It’s expected to be licensed to give to pregnant women. Infants would be protected by passive immunity as antibodies pass through the placenta.

Will Humble Public Health, Wills Blog

Public Health Journalism this Week

Will Humble State Legislature, Wills Blog

Legislative Update: May 8, 2023

The House and Senate came in for some brief business on Wednesday, May 3 and then adjourned again until tomorrow. The House now has its full contingent of members, while the Senate is still down one member until the MC Coard of Supervisors names a replacement for Sen. Teran.

Floor votes have been scheduled in both the House and Senate for Monday and I expect that to continue throughout the week. So far none of the bills that we’ve taken positions on are up for votes next week – but that could change quickly.

There are rumors of a budget deal between the Governor and House & Senate leadership – but word is that the Appropriations chairs haven’t been involved – which is unusual.

Two good things happened last week. Both chambers passed a bill to give AHCCCS expenditure authority to draw down federal dollars. The Governor signed it quickly. 

Without that authority, AHCCCS wouldnt have been able to make May payments to their contracted health plans, which could have delayed payment to providers. 

In another development, we avoided a potential trainwreck in Arizona’s emergency management system last Wednesday. HCR2039 governor; state of emergency, which would have dismantled the Recovery phase of emergencies in Arizona (had the voters approved it) was derailed.

Last-minute questions by Senator Bennett in last Wednesday’s (R) caucus meeting about that ballot referral got the attention of other Republican members. It appeared after the Caucus meeting that the Resolution won’t be going to the Senate floor after all.

Ballot Referral Could Dismantle Arizona’s Emergency Management System

If voters ended up approving it, it would have ended Governor-proclaimed states of emergency after 30 days (including public health emergencies) unless extended by the Legislature in 30-day increments. It would impact all declared emergencies like floods, fires, chemical spills, and other kinds of disasters – not just public health emergencies.

Had it not been stopped last week it would have gone directly to the ballot in November 2024 (Governor Hobbs is unable to veto ballot referrals).

See our Legislative Session Working Powerpoint with the bills we’ve taken positions on.
Will Humble Return on Investment, Wills Blog

U.S. Department of Education College Scorecard

The Education Department unveiled changes Tuesday to its College Scorecard which now includes data about what college graduates make four years after completing their degrees and student debt trends. The Department of Education Scorecard is designed to help prospective students “find high-value postsecondary programs” that align with their goals. 

The Scorecard was originally developed during the Obama administration as an online tool with data about college costs, acceptance rates, graduation rates and student body diversity. Its original intent was to just prospective students, families, educators, and others information to help them compare colleges.

The new features let students also explore what they might expect as a salary early in their career for all levels of degrees (bachelors, masters, doctorate). Tuition costs and scholarship/grant availability are also indirectly captured as the tool lets students see Folks can also compare median debt and monthly debt payments for various university degrees by school.

I did a quick query for the UA College of Public Health Bachelor’s & Master’s degree programs below. Anyway- I just thought this is an interesting tool for both parents and students to explore as they think about fields of study and colleges.

University of Arizona Bachelor’s Degree in Public Health

MEDIAN EARNINGS 4 YEARS POST GRADUATION: $47,452

MEDIAN DEBT: $21,000

University of Arizona, Master’s Degree in Public Health

MEDIAN EARNINGS 4 YEARS POST GRADUATION: $76,477

MEDIAN DEBT: $47,242

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