Will Humble Behavioral Health, Wills Blog

Arizona State Hospital Governance Reform Remains in Limbo

One of our continuing priorities other than things in the budget is to get better governance in place at the Arizona State Hospital.  SB1716 Arizona State Hospital; Governing Board. The bill (by Senator Gowan) would change 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 sets 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. Here’s an article by Mary Jo Pitzl at the Arizona Republic with more detail. The Arizona Department of Health Services would then be able to regulate the Arizona State Hospital free from conflicts of interest.

Why is that important? It’s simple. Right now, there’s 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. 

Editorial Note: I submitted a complaint to ADHS Licensing more than a month ago, after there were more than 7 Code Grays in a single day at the State Hospital (Code Gray’s mean that there was an assault bad enough to require a significant intervention). I received an automated response suggesting that they would follow up. To date I have heard nothing about what the status of that complaint is.

That bill continues to languish, needing a hearing in the House Rules Committee and then a floor vote in the House before going to the Governor for a signature (the bill had consensus support in the Senate). We’re continuing to make sure legislators know how important this bill is!

See: How is the Arizona State Hospital Regulated & Why is Governance Reform Needed?

Will Humble Social Determinants, Wills Blog

Ducey Administration Failure to Implement Unemployment Insurance Identity Verification Resulted in $4.4 Billion Dollars in Fraudulent Payouts

More than 31% of ADES Unemployment Insurance Claims Paid Out During the Christ/Betlach Leadership Era were Fraudulent- to the Tune of Billions of Dollars

The Arizona Auditor General’s Office plays a key role in keeping state government accountable in several ways. They help State agencies, universities, community college districts, counties, school districts, and other governmental entities work better by analyzing their operations and recommending improvements, so they spend and account for public monies appropriately, efficiently, and effectively. In fiscal year 2021, the Auditor General issued 171 audits, reviews, investigations, and follow-ups with 624 recommendations.

Their audits and reviews assess how various State governmental entities, such as State agencies and school districts are performing—that is, how well they are fulfilling their statutory mandates and serving Arizona’s citizens. Sunset reviews help the Legislature decide whether to continue or terminate (“sunset”) an agency. There were two key reports recently published that highlight this important work.

Unemployment Insurance Fraud

In a new report this week, the auditors found disturbing financial irregularities in which ADES (during the Christ Betlach leadership era) misspent and fraudulently distributed literally billions of dollars in federal funds. That report, published on May 25 for the Joint Legislative Audit Committee meeting found that:

During the time when Acting Director’s Christ and Betlach were in charge of the Arizona Department of Economic Security, the agency failed to put identity verification or other anti-fraud measures in place and ended up over $1.6B in fraudulent unemployment insurance claims out of the $5.1Billion dollars in total claims paid as of June 30, 2020. In other words, more than 31% of the unemployment insurance claims paid out through June 30, 2020 were fraudulent!

ADES paid an additional $2.8 billion in fraudulent claims between June 30, 2020 through September 4, 2021, for a total of $4.4 billion of fraudulent claims paid! See Page 4 of the Joint Legislative Audit Committee report.

It’s unclear whether any kind of punishment is in the offing from the federal government for this astonishing lack of attention to detail.

Will Humble Vaccination, Wills Blog

COVID Vaccine for Kids Under 5 Years Old Finally On the Way: Here’s How the Rollout Will Work

Parents with kids under 5 years old have been anxiously awaiting an opportunity to get their kids vaccinated for COVID-19. In fact, it’s been more than 18 months since vaccine was authorized for adults. Many things slowed down the process, but primarily because the clinical trials for kids under 5 were the last to be conducted and the dosing and spacing of the vaccine to determine safety and efficacy was trickier.

The day parents of toddlers have been waiting for is finally almost here. The FDA’s advisory committee (Vaccines and Related Biological Products Advisory Committee) is meeting on June 14th and 15th and is expected to recommend that the FDA Director issue an emergency use authorization of the Pfizer and Moderna vaccine for kids 6 months old to 5 years old shortly after the meeting. CDC is expected to quickly follow suit and recommend the vaccine.

The Pfizer vaccine will be a 3-dose series with the second shot 3 weeks after the 1st and the final dose 2 months after that. The Moderna series will be 2 doses 4 weeks apart. Clinical trials found that the Pfizer 3-dose series was 80% effective at preventing infection while Moderna’s 2 shot series came in at about 40%. Perhaps that 3rd dose is making the difference. Also, keep in mind that the clinical trials were conducted pre-Omicron, so the actual efficacy for both may be a smidge lower.

In anticipation of FDA authorization & CDC recommendation, states are now able to start ordering vaccine for 6 months to 5-year-olds. Arizona’s initial allocation is about 200,000 doses. There are roughly 400,000 kids under 5 years old in Arizona, so the initial tranche should cover roughly ½ of Arizona kids for their first dose.

Any pediatric, family practice provider or pharmacy that’s enrolled in ADHS’ Arizona State Immunization Information System (ASIIS) and has gone through the ADHS’ COVID vaccine ‘on-boarding process’ can order vaccine starting today (pharmacists can only vaccinate kids 24 months old and up… so some pharmacies may elect to not order the under 5 vaccines).

Ordering is through ASIIS, with a 200-dose maximum order limit for all providers that aren’t county health departments or tribal entities. Expected delivery for the first shipment of pediatric (under 5) doses is June 20th with a subsequent delivery expected on the 21st (contingent on those FDA & CDC decisions).

The supply of the new pediatric vaccine is expected to increase rapidly by the end of the month, and the 200-dose maximum order is expected to be dropped by the end of June.

Special Note: The ADHS, county health departments, and tribal partners collaborated to come up with the distribution plan (far different from the Director Christ era when partners found out major policy decisions in an ADHS media release or on the news).

Will Humble State Legislature, Wills Blog

Leaked Draft State Budget Has Some Encouraging Health & Human Services Line Items

I managed to get my hands on a leaked draft state budget this morning. Word on the street (from reliable sources) is that this version has the support of legislative leadership & the governor’s office but not necessarily support from enough rank-and-file legislators.

I went through the changes from last year’s Joint Legislative Budget Committee in the health and human service areas & found some encouraging increases in several areas. I don’t know if the dollar figures noted in this draft are sufficient, but it was encouraging to see that there is some support in the governor’s office and among leadership for some important changes. Note: I didn’t go through the list of needs for public education- I just stuck to my wheelhouse in the health and human services sector.

Here’s a link to the leaked spreadsheet. Below are some bullets summarizing the increases over last year’s baseline (I highlighted the health and human service line items in green):

 

AHCCCS

Postpartum Care ($2.7M)

Pregnancy Care Rate Increase ($10M)

ALTCS Elderly Rate Increase ($24M)

Allowing Kids Care to Stay Eligible for 1yr ($600K)

Secure Behavior Health Facility Rate Increase ($10M)

Behavioral Health Worker Training ($5M – Federal)

Clinical Rotations ($27M – Federal)

Secure Behavioral Health Facilities ($25M)

 

Department of Economic Security

More Adult Protective Services Staff ($11.2M)

Early Intervention Rate Increases (Federal)

Developmental Disability Provider Rate Increase ($56.7M or 9.7%)

Other DD Rate Increase (efficiency) ($7.2M)

 

ADHS

Behavioral Health Practitioner Student Loans ($2M)

AZ State Hospital Hiring Bonus ($700K)

AZ State Hospital Increased Staffing ($6.9M)

 

Department of Child Safety

Healthy Families Expansion ($10M)

Foster Care Stipend Increase ($4.8M)

Kinship Stipend Increase ($19.8M)

 

Note: We’re not endorsing this as a final budget but at least there are some encouraging new increases in the health and human services sectors. Of course, more analysis needs to be done…  but I wanted to get this out in the public domain for all to see for analysis and advocacy purposes

Will Humble Opioids, Wills Blog

UA Center for Rural Health Helping Rural Providers w/ Medication Assisted Treatment for Opioid Use Disorders: Slots Still Available

Medication assisted treatment (MAT) is an evidence-based practice to help patients with substance use disorder including opioid use disorder. Yet, access is limited particularly in rural counties. In 2020, federal requirements changed to expand providers’ ability to offer MAT in office-based settings. 

Providers who are new to offering MAT often need some additional technical support to get started providing this important evidence-based service. That’s where the Arizona Center for Rural Health’s AzMAT Mentors Program comes in. Their team support new & less experienced MAT providers to get them off the ground or to help them implement more effectively & serve more folks.

Space is still available for less experienced MAT providers interested in collaborating with an experienced MAT provider. Participation is free and is an effective way to build capacity to offer treatment. Visit https://crh.arizona.edu/mentor

Will Humble Opioids, Wills Blog

What’s Up with All that Opioid Settlement Money & How Come There’s No State Plan for It Yet?

I’m sure you’ve heard about the settlement agreement that was finally reached in a multi-state lawsuit (including Arizona) against Cardinal, McKesson, AmerisourceBergen, and Johnson & Johnson – punishing the firms for their unethical behavior as they marketed their opioid products.

Arizona is set to receive $542 million over the next 18 years to combat an ongoing epidemic after the defendants and state plaintiffs $26 billion settlement for their roles in the opioid crisis. Settlement funds will be disbursed to the state and its subdivisions.

90 cities and towns and all 15 counties are signed on to a framework called the One Arizona Memorandum of Understanding (One Arizona Plan) to expeditiously distribute funds. The One Arizona Plan provides funding for programs to address and ameliorate opioid abuse, and includes reporting requirements for greater transparency of how money is used:

  • 56% of the total settlement will go to local governments for opioid mitigation programs.
  • 44% of the total settlement goes to a State for yet to be determined interventions.
  • Funds must be spent in accordance with approved, nationally recognized strategies to pay for future costs incurred by the State and local governments to address the opioid epidemic.

The funds are in some ways restricted in that they are supposed to go directly to relief and resources related to opioids, including to diversion programs to prevent people from going to prison for an addiction or substance-use disorder.

Because these are long-term funds that recently became available, there’s still not a lot of granularity about how the state and local jurisdictions intend to invest the funds… but county staff is certainly undergoing planning to make sure that they wisely use the funds. A priority for Pima County is to make sure they get input from the community before making decisions- always a good idea.

There’s no information on the ADHS website about the opioid settlement funds. If you do a google search, you’ll see that other states have info about the settlement on their website, but not in Arizona. Perhaps the executive branch is yet to decide whether ADHS or AHCCCS will be the primary recipient of the funds. Who knows?

In any event- we will have a new governor in just 208 days, so perhaps the new governor and their leadership team will finally put together a comprehensive plan for the state funds that will work hand in hand with the counties and cities. Frankly, I think the best steward for the state funds would be AHCCCS rather than ADHS (given current leadership).

Will Humble Professional Development, Wills Blog

State and County Health Departments Launch ‘AZ Public Health Connect’ to Provide Support for Public Health Workers

AZ Public Health Connect

Thanks to a new initiative by the state and county health departments, the public health workforce can enroll now to receive twice-weekly supportive text messages by texting AZPHconnect to 60298. (http://slkt.io/7YfV)

A workgroup made up of Arizona county health partners & ADHS team members is developing messages and resources that public health professionals can use to implement well-being into their daily lives. These texts include encouraging messages and resources on self-care, gratitude, and social connection.

For a little background on the program, the Arizona Nurses Association created the RN Connect 2 Well-being initiative designed to support nurses facing significant burnout, fatigue, and increased stress.

Arizona nurses were invited to enroll in a free text messaging program that provided 2x weekly messages with tips on various topics such as stress management, mindfulness, and healthy living. The RN Connect program was successful in providing well-being support for Arizona nurses and has allowed for the opportunity to extend this service to Arizona public health professionals.

The Arizona Nurses Association has graciously allowed the state county health department team to use their platform for the new AZ Public Health Connect (AZPH Connect) for the public health workforce.

Following the model of the RN Connect 2 Well-being initiative, public health professionals are encouraged to enroll in the AZ Public Health Connect program as a way to get a little extra support and encouragement.  We anticipate the first text messages to begin the week of June 6, but people can continue to enroll after that date.

See this promotional flyer for more information and feel free to share this well-being resource with your Arizona public health partners. For questions, more information, suggestions, or to express interest in joining the workgroup of public health professionals developing the messaging, please contact Erika Garcia at erika.garcia@azdhs.gov

It’s been a pleasure working on this new initiative for the public health workforce, and I hope you will find it to be of value for yourself.

Sheila Sjolander, MSW

Assistant Director

Division of Public Health – Prevention Services

 

Will Humble Air Quality, Wills Blog

Time Running Out for Cleaner, Healthier Future

Time Running Out for Cleaner, Healthier Future

Our state’s continued dependence on fossil fuels jeopardizes Arizona’s health and climate today and will continue to do so into the future – unless we act now.

Once again, we see Arizona communities ranked among the most polluted in the United States. The American Lung Association’s “State of the Air” 2022 report puts a fine point on this – Pinal County is one of just a handful of communities in the United States to earn failing grades for ozone, short-term and annual particle pollution levels. In fact, Pinal County is considered the 18th most polluted county in the U.S. for annual particle pollution levels.

Phoenix, the largest and most populated metro area, faces even greater challenges with air quality. Although this year’s report found fewer days of unhealthy ozone, Phoenix saw increases in both short-term and annual particle pollution levels. It remains one of the most polluted cities in the U.S., ranking as the fifth smoggiest city, and eighth most polluted in terms of year-round soot, nestled between California cities on each list.

Exposure to air pollution causes respiratory issues such as lung inflammation, chest tightness, and severe asthma attacks. It also contributes to cardiovascular harm including heart attacks, strokes and, in extreme cases, premature death. While poor air quality is dangerous for all, it disproportionately impacts vulnerable populations such as children, the elderly, low-income individuals, and people of color. Nationally, people of color are 3.6 times more likely to live in a county with failing air quality for ozone, short-term and annual particle pollution than white people.

People living near major transportation hubs and electricity generating power plants are at even greater risk. This is especially true for residents of Randolph in Pinal County, which is home to some of the most polluted air in the United States. This is why the Arizona Corporation Commission’s decision to deny expansion of fossil fuel combustion at the Coolidge Generating Plant was a necessary step to avoid adding yet more emissions in Pinal County. This decision should send a clear message to utilities and state leaders: we must transition away from fossil fuels and invest in renewable, non-combustion energy today.

Last month, another report by the Lung Association, “Zeroing in on Healthy Air,” illustrated the potential health and climate benefits if we were to transition to a zero-emission transportation sector and shift to clean, renewable energy. Acting now could result in $15.1 billion in public health benefits in Arizona over the coming decades – this includes 1,360 avoided deaths, 38,500 avoided asthma attacks, and 32,300 avoided lost workdays.

Moreover, some of the most impacted communities can reap the greatest health benefits. The report looked at the 100 U.S. counties with the highest percentage populations of people of color, approximately $155 billion in health benefits are projected – and swift action will benefit all Americans.

The more we delay investments in transportation electrification and renewable energy, the more health savings we leave on the table. Delays are something Arizona cannot afford, and something Arizonans do not want.

Last year, a poll of Arizona voters revealed 75% of voters support shifting investments away from fossil fuels like coal, oil and gas and toward clean, non-combustion energy sources and technologies like wind, solar and zero-emission vehicles.

The research is clear, and voters have spoken – we must act on our climate crisis and make bold investments in zero-emission technologies to protect the health of all Arizonans.  Our health and well-being depend on a rapid transition to zero emission technologies, especially in communities like Pinal County which faces some of the worst air pollution in the United States.

 JoAnna Strother is senior director of advocacy for the American Lung Association in Arizona. 

Will Humble is executive director of the Arizona Public Health Association and former director for the Arizona Department of Health Services. 

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Will Humble Medicaid, Wills Blog

Federal Public Health Emergency Likely to Extend to October 15, 2022: Here’s What that Means

Back on April 15, HHS Secretary Becerra extended the federal public health emergency for COVID-19 to July 15 [See renewal declaration here]. Both he and the president have said that they will give states 60 days’ notice if they intend to let the public health emergency expire.

This week that 60-day notice period came and went, meaning we can count on the federal government to keep the emergency in place through October 15. Many policy changes are tied to the federal public health emergency like flexibilities to waive or modify certain requirements in a range of areas, including in the Medicare, Medicaid, and CHIP (KidsCare) programs, mandates for private health insurance, authorization of medical countermeasures, telehealth, providing liability immunity to providers who administer services, and authorizing the FDA to do emergency use authorizations, among other things:

The Kaiser Family Foundation out together this good summary of what changes are coming when the federal declaration ends: What Happens When COVID-19 Emergency Declarations End? Implications for Coverage, Costs, and Access

Here are the sub-categories:

The thing I’m most concerned about is that once the federal emergency ends on October 15, AHCCCS will begin its redetermination processes. AHCCCS estimates that as many as 500,000 members have moved in the last 2 years and didn’t update their address. Once the federal emergency ends, they’ll send out notices to members and those that don’t reply will eventually get kicked off.

Thankfully AHCCCS and their contracted managed care organizations are working hard up front to make sure folks that have moved in the last year update their addresses at www.healthearizonaplus.gov or 1-855-432-7587.

Listen to Director on KJZZ’s The Show Here

Will Humble Assurance & Licensure, Healthcare, Wills Blog

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

Auditor General’s Report of the Arizona Department of Health Services Nursing Home Complaint Investigation Performance

Every 10 years the bigger state agencies go through what’s called a Sunset Review – which is the state legislature’s way of examining the performance of state agencies and determining whether they still need to exist or require major reform. The legislature often asks the Auditor General’s Office to review the performance of specific areas and write a report.

That Sunset Review for ADHS happened back in 2019. The Auditor General reviewed ADHS’ performance with respect to following up on nursing home complaints (ADHS is the regulatory authority for nursing homers).

That 2019 Arizona Auditor General Report found, among many other things, that ADHS (during the Director Christ era) failed to investigate, or timely investigate or resolve many long-term care facility complaints. The report laid out 4 key areas where performance improvement was needed. Director Christ (and Deputy Colby Bower) made promises at the time to make the improvements. The state legislature even followed through, giving the agency an additional $1.6M to hire staff.

The auditor general’s team came back in 2021 to see whether the ADHS had made any improvements. Astonishingly, the report issued this week concluded that the agency had not implemented any of the required changes, and also found these disturbing findings:

  • Between 7/1/19 and 4/21/21 ADHS, under the leadership of former Director Christ and Assistant Director Colby Bower, lowered the priority level of 98% of their open high priority complaints, giving them months more time to investigate and giving the appearance they were making improvements (high risk complaints need to be done in 10 days vs months for the others).
  • ADHS leadership CLOSED 79% of those former high priority complaints without ever doing an investigation.
  • ADHS leadership CLOSED 82% of high priority facility self-reports after changing them to medium and then closing without an investigation.
  • In the second half of 2019 (before the 1st auditor general report) ADHS had classified 42% of nursing home complaints as high risk. After the report was published – the percentage of complaints classified as high risk dropped to only 4% (July – Dec. 2020).
  • ADHS did not post complaints on AZCARECHECK (the public disclosure site) unless there was an investigation…  but because they closed out the vast majority of complaints without an investigation, thousands of those complaints never made it to their website- further greatly limiting the ability of family members to make informed decisions.

The interim joint committee of reference is asking for quarterly reports from ADHS, told ADHS to be transparent about how they classify complaints, legislature will make sure CMS knows about the audit reports, the ADHS is supposed to fully cooperate with the auditors on follow ups. No mention of the committee urging state or county law enforcement investigations though.

Note: To be fair to the current ADHS leadership team- the review period for the Auditor General’s Report was from July 1, 2019 through April 21, 2021. Director Christ was the agency director for that entire period and Colby Bower was the head of Licensing. Both of those persons left the agency in late 2021 and now are in well paying senior leadership positions at Blue Cross Blue Shield of Arizona.

AZ failed to properly investigate nursing home complaints
Read the ADHS Auditor General’s Report
Arizona regulators skipped inspections of long-term care facilities

From the new Auditor General Report:

‘As described in the transmitted follow-up report, we found that the Department has not implemented any of the 5 recommendations from our September 2019 report, and we identified additional significant complaint-prioritization and investigation failures that have continued to put long-term care facility residents’ health, safety, and welfare at risk.’ For example:

  • Contrary to federal requirements, the Department inappropriately closed most High-Priority complaints/self-reports without a required on-site investigation, including complaints involving allegations such as lack of pressure sore precautions, residents being left soiled for an extended time, and abuse or neglect.
  • Of the 156 High-Priority complaints the Department investigated, it failed to initiate the on-site investigations for 73% of these within the required 10 working days. 
  • The Department inappropriately changed 98% of its open High-Priority complaints to lower priorities, which artificially extended the time frame for responding to these complaints/self-reports from 10 days to 1 year.
AZ failed to properly investigate nursing home complaints, report says

The key to whether the agency fixes these potentially lethal deficiencies lies with whether Interim Director Herrington admits to the program failures and commits to fixing the problems. If he stonewalls as his predecessor did, we will likely be stuck with poor performance until the next administration.

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