Will Humble Federal Public Health Bud, Health Equity, Healthcare, Medicaid, Wills Blog

Center for Medicare & Medicaid Services Approves AHCCCS’ Home & Community Based Services Action Plan

Last week AHCCCS put out an under-stated media release announcing that CMS approved their Home and Community Based Services (HCBS) Spending Plan, which would use $1.5B in mostly American Rescue Plan Act funds over the next 2 years to improve Home and Community Based Services for folks in their Long Term Care Program (ALTCS). Even though this is mostly federal money (it will require some state match) implementing it will require approval of the Legislature and Governor.  We will play a role in trying to make that happen.

Here’s a link to their 30-page plan which is of course written in dense AHCCCS/CMS language – but the takeaway is that they would bump up the per member per month capitation rates by 10% and then have some performance expectations tied to those funds in areas like:

  • Promoting stabilization, access to supportive services, and workforce retention/ consistency to improve member outcomes ($1B)
  • Expanding access to care from a “well-trained, highly-skilled workforce” ($217M)
  • Supporting individual self-sufficiency by connecting members to technological tools and resources that promote independence ($96M)
  • Using new technology to promote care coordination and seamless communication ($74M)
  • Funding local initiatives and community-specific programming to improve member health ($62M)
  • Empowering parents and families to provide care and meet the needs of their kids ($27M)
  • Assessing member engagement and satisfaction to better understand needs, prevent abuse and neglect, and identify opportunities for improvement ($5M)
  • Creating tools that strengthen quality monitoring and prevent abuse and neglect ($3.2M)

AHCCCS’ spending plan has all the particulars for how they want to spend this money in the various categories, but the biggest category by far is the first bullet; to build the caregiver workforce.

The detail on the spending plan is for temporary payments to providers for sign-on bonuses, retention payments, mileage reimbursement, reimbursement for tuition or continuing education, reimbursement for childcare and/or enhanced insurance coverage. 

Because the money ends in March of 2024 “AHCCCS will establish appropriate criteria to ensure that provider recruitment and retention strategies do not create an expectation of ongoing benefits, given the time-limited nature of this funding opportunity“.

For more information about the spending plan and CMS’ response, please visit the AHCCCS ARPA webpage.

Will Humble Disease Control, Wills Blog

Arizona Has the 2nd Highest COVID-19 Death Rate Per Capita During the First 2 Years of the Pandemic

Dr. Gerald’s Weekly COVID-19 Epidemiology & Hospital Occupancy Report

As we pass the 2-year mark for the pandemic, Arizona is distinguished to have the 2nd highest number of COVID-19 deaths per 100,000 in the U.S., with a death rate of 348/100,000. Only Mississippi has a higher COVID death rate at 357/100,000.

Assuming current trends continue (and there’s no reason to believe they won’t- given the lack of interest in mitigation by Doug Ducey & Don Herrington), Arizona will have the highest per-capita COVID death rate in the entire U.S. by mid-February.  A dubious distinction indeed, and one that is mainly attributable to the decisions made by Doug Ducey, ADHS Interim Director Don Herrington, and former ADHS Director Cara Christ.

Summary of this week’s report by Dr. Joe Gerald:

Arizona is experiencing historic levels of community transmission attributable to the dominant Omicron variant. Test positivity is insanely high reminding us that test capacity, accessibility, and/or uptake is wholly inadequate. Transmission (cases) has likely peaked as you read this but expect high levels of hospital through February. The greatest burden on our health care system will remain in hospital wards and emergency departments.

As of January 16th, new cases were being diagnosed at a rate of 1896 cases per 100K residents per week. We can expect rates to peak ~2000 cases per 100K residents/week, somewhat lower than some other states perhaps due to less testing availability. Ideally, a peak would be indicated by declining case counts and test positivity. Hopefully, next week’s update will bring confirmation of both.

Even if Arizona is moving down the backside of the wave, it is still important that all adults who previously completed the 2-dose primary sequence to obtain a booster, particularly those 50+ years of age. The risk of Omicron infection will remain extremely high for many weeks. Remember, the CDC defines high community transmission as levels >100 cases per 100K residents per week. We’re a far cry from that!

COVID-19 hospital occupancy (wards) continues to increase but should moderate soon. Hospitals will continue to be burdened by >30% occupancy in general wards and in the ICU for several weeks yet. Access to care continues to be restricted by both COVID-19 occupancy and staff shortages owing to infections among healthcare workers.

Weekly COVID-19 deaths likely peaked at 530 deaths the week ending December 12th. However, weekly totals in the upper-300s, lower-400s are likely for several more weeks. So far, at least 25,502 Arizonans have lost their lives to COVID-19.

Will Humble Health Insurance, Healthcare, Wills Blog

Federal No Surprises Act Protects Arizonans From Surprise Medical Bills

The No Surprises Act (backed by Sen. Mark Kelly) went into effect a couple of weeks ago. It was passed in Dec. 2020 as part of a larger COVID relief bill called the Consolidated Appropriations Act of 2021. It protects patients when they receive emergency care or scheduled treatment from doctors and hospitals that aren’t in their insurance networks and that they did not choose. From now on, Arizonans are only responsible for their in-network cost-sharing in these situations.

A pre-existing Arizona law from 2019 (Senate Bill 1441) only created an out-of-network claim dispute resolution process covering cost sharing of at least $1,000.

CMS recently released several new resources to assist with the implementation of the No Surprises Act. The documents include a series of frequently asked questions related to the federal independent dispute resolution process and notice of consent requirements and frequently asked questions related to the uninsured and self-pay good faith estimates.

Will Humble Health Equity, Prevention, Public Health, Social Determinants, Wills Blog

Maricopa County Department of Public Health Issuing $12M in Health Disparity Grants

 Here’s Where to Learn More

The Maricopa County Department of Public Health is offering up to $12 million in health disparities grant funding to agencies, municipalities, and other organizations among 5 regions in Maricopa County.

The funding will be used to help develop and work through strategies and interventions that consider systemic barriers and potentially discriminatory practices. COVID-19 and the ripple effects of economic and school closures, job loss, isolation, etc. has meant that many families and individuals did not see healthcare providers for regular checkups, increasing the likelihood of undiagnosed or unmanaged chronic illnesses, oral health, mental health, etc. 

Funding must support Policy, System and Environmental changes that can impact the disparity gap for vulnerable and marginalized populations. Funds are not intended for direct services or direct financial distribution to the public. Funding will be awarded via 5 opportunities for the following regions:

Visit www.maricopahealthmatters.org to learn more about our regions and community health needs assessment data.

Attend the Virtual Pre-Bid Conference to learn more about this opportunity Monday, January 24, 2022 at 1:00pm Join Here. Questions go to Cheryl Bucalo, Procurement Officer @ (602) 506-6886 or [email protected]

Will Humble Disease Control, Wills Blog

Journal Article of the Week: Clinical outcomes among patients infected with Omicron SARS-CoV-2 variant in southern California

Clinical outcomes among patients infected with Omicron SARS-CoV-2 variant in southern California

Results: Our analyses included 52,297 cases with Omicron and 16,982 cases with Delta infections, respectively. Hospital admissions occurred among 235 (0.5%) and 222 (1.3%) of cases with Omicron and Delta variant infections, respectively. The adjusted hazard ratios for any subsequent hospital admission and symptomatic hospital admission associated with Omicron variant infection were 0.48 (0.36-0.64) and 0.47 (0.35-0.62), respectively.

Rates of ICU admission and mortality after an outpatient positive test were 0.26 (0.10-0.73) and 0.09 (0.01-0.75) fold as high among cases with Omicron variant infection as compared to cases with Delta variant infection.

Conclusions: During a period with mixed Delta and Omicron variant circulation, SARS-CoV-2 infections with presumed Omicron variant infection were associated with substantially reduced risk of severe clinical endpoints and shorter durations of hospital stay.

Will Humble Disease Control, Environmental Health, Public Health Law, Vaccination, Wills Blog

Legal Analysis for the OSHA & CMS Vaccine Requirement Regulations

National Federation of Independent Business v. Department of Labor & Ohio v. Department of Labor

Biden v. Missouri and Becerra v. Louisiana

Blog prepared exclusively for the Arizona Public Health Association

Jennifer L. Piatt, J.D.

On January 13, 2022, the Supreme Court of the United States issued two opinions addressing federal COVID-19 vaccination requirements. In National Federation of Independent Business v. Department of Labor and Ohio v. Department of Labor (“The OSHA Cases”), the Court blocked enforcement of the Occupational Safety and Health Administration (OSHA) COVID-19 Emergency Temporary Standard (ETS) for certain U.S. workplaces.

In Biden v. Missouri and Becerra v. Louisiana (“The CMS Cases”), the Court allowed a Centers for Medicare and Medicaid Services (CMS) rule to take effect requiring providers to ensure that staff are vaccinated against COVID-19. The Court’s decisions turn on the Justices’ interpretations of federal agency powers.

The OSHA Cases: On November 5, 2021, OSHA promulgated the ETS, generally requiring workplaces with more than 100 employees to implement employee COVID-19 vaccine-or-test policies. The ETS faced instantaneous opposition in courts across the nation by several states, businesses, and other organizations. On December 17, the Sixth Circuit rejected preliminary challenges to the ETS, finding in part that OSHA had clear authority to “protect workers against infectious diseases.”

The Supreme Court disagreed. In blocking enforcement of the ETS, the Court reasoned that the Secretary of Labor, through OSHA, does not have the authority to issue “broad public health measures.” Rather, under the Occupational Safety and Health (OSH) Act, the Secretary may regulate “occupation-specific risks” and set “workplace safety standards.”

The Secretary may not “regulate the hazards of daily life,”—public health threats which are not unique to the workplace. The Court left a small amount of room for a narrower standard addressing “special danger[s]” COVID-19 might pose in a particular working environment. In a blistering dissent, Justices Breyer, Sotomayor, and Kagan criticized the majority for placing limitations on OSHA’s authority that do not appear in statute.

The CMS Cases. CMS promulgated its own rule requiring COVID-19 vaccination of program participant staff on November 5, 2021, causing a similar flood of nationwide litigation. After several inconsistent lower court rulings, the Supreme Court allowed the CMS COVID-19 vaccine mandate to take effect, concluding that the Secretary of Health and Human Services was plainly authorized to issue it.

The Secretary can set requirements necessary for the “health and safety of individuals” receiving program services, and the CMS vaccine mandate clearly falls within the scope of that authority. Vaccine requirements in healthcare settings are common, they help keep patients safe, and CMS routinely imposes conditions of participation for receipt of funds. Justices Thomas, Alito, Gorsuch, and Barrett dissented, arguing CMS does not have the authority to issue a vaccine mandate.

The Court’s decisions are not the end of the road—in theory, they simply indicate whether the rules can or cannot be enforced while federal courts consider the legal challenges to them.

The ETS (ASHA Rule) has been blocked pending further litigation, while the CMS mandate can take effect. Still, with a clear 5-4 vote supporting the CMS mandate, and a clear 6-3 vote against the OSHA ETS, lower courts may be inclined to follow these interpretations.

Jennifer L. Piatt, J.D., LL.M., is a Research Scholar, Center for Public Health Law and Policy, Sandra Day O’Connor College of Law, Arizona State University.

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Which Entities & Employees are Covered Under the CMS Vaccine Requirement?

Now that the CMS vaccine requirement is settled law (probably) who does it apply to? Here is CMS’ Guidance Memo with the details. The staff vaccination requirement applies to the following Medicare and Medicaid-certified provider and supplier types:

Ambulatory Surgery Centers, Community Mental Health Centers, Comprehensive Outpatient Rehabilitation Facilities, Critical Access Hospitals, End-Stage Renal Disease Facilities, Home Health Agencies, Home Infusion Therapy Suppliers, Hospices, Hospitals, Intermediate Care Facilities for Individuals with Intellectual Disabilities, Clinics, Rehabilitation Agencies, Outpatient Physical Therapy and Speech-Language Pathology Services, Psychiatric Residential Treatment Facilities, Programs for All-Inclusive Care for the Elderly Organizations, Rural Health Clinics/Medicare Federally Qualified Health Centers, and Long Term Care facilities.

Will Humble Disease Control, Public Health, Vaccination, Wills Blog

Test Positivity Reaches 60% with 175,000 COVID Cases Reported Last Week in Arizona: Ducey & Herrington Remain At Large

View the Full Epidemiology & Hospital Occupancy Report

Arizona is experiencing historic levels of community transmission attributable to the newly dominant Omicron variant.  Test positivity is insanely high (60%) reminding us that test capacity, accessibility, and/or uptake is wholly inadequate. Arizona, like much of the United States, is in the midst of another large pandemic wave. Expect transmission to peak in late January with very large numbers of hospitalizations continuing into February. The greatest burden on our health care system will shift towards emergency departments and general wards and away from our ICU facilities.

As of January 9th, new cases were being diagnosed at a rate of 1494 cases per 100K residents per week. Given the experience of eastern states, we can expect this rate to likely peak in the ballpark of 3000 cases per 100K residents per week before the end of the month. Given it is now January 15th, rates are considerably higher as your read this in the moment. For example, the ADHS Dashboard recorded a whopping 24,964 cases on January 15th which is roughly equivalent to 175,000 per week!

Mask mandates were needed at municipal and county levels to reduce transmission, blunt the worst of the Omicron wave, and relieve overwhelmed hospitals. Now, hospitals will just have to grin and bear it.

COVID-19 hospital occupancy is once again increasing and should continue to do so throughout January. Hospitals should prepare for >30% occupancy in general wards and in the ICU. Access to care will continue to be further restricted in the face of staff shortages owing to infections among healthcare workers. However, healthcare workers have told to “suck it up, Buttercup” and work even if COVID-19 positive.

January, and perhaps early February, will be hospital’s most difficult month with the tail of the Delta wave, below average but still meaningful seasonal influenza, and a large Omicron surge.

Weekly COVID-19 deaths have now reached 500 per week and should remain at or below this level as the tail end of the Delta wave recedes. So far, 25068 Arizonans have lost their lives to COVID-19.

Editorial Note: I’ll spare you any editorial notes this week. At this point, one just has to throw their hands up and say- well, if these circumstances won’t convince Ducey & Herrington to do anything, nothing will.

Will Humble Disease Control, Public Health Law, Vaccination, Wills Blog

U.S. Supreme Court Upholds CMS’ Vaccine Requirement; Strikes Down OSHA’s Vaccinate or Test Rule

The Supreme Court just stopped enforcement of OSHA’s emergency rule that would have required employers with more than 100 staff to require that their team be vaccinated or undergo periodic testing. The court said that OSHA doesn’t have the authority to impose the vaccine or test requirement. In the unsigned opinion called National Federation of Independent Business v. OSHA the court wrote that:

Although Congress has indisputably given OSHA the power to regulate occupational dangers, it has not given that agency the power to regulate public health more broadly. Requiring the vaccination of 84 million Americans, selected simply because they work for employers with more than 100 employees, certainly falls in the latter category.

The vote on the OSHA provision was 6-3 with the usual cast of characters voting exactly as you would expect.

However, the court upheld CMS’ new requirement that people employed at health care facilities that receive federal Medicare and Medicaid be vaccinated. That measure will now take effect this month and will covers about 10 million workers nationally, about 200,000 workers in AZ.

In that case, called Biden v. Missouri the 5-4 court majority held that CMS does have the authority to implement the vaccine requirement. The majority wrote that:

The challenges posed by a global pandemic do not allow a federal agency to exercise power that Congress has not conferred upon it. At the same time, such unprecedented circumstances provide no grounds for limiting the exercise of authorities the agency has long been recognized to have.

Dissenting were Thomas, Alito, Gorsuch and Barrett.

Will Humble Air Quality, Disease Control, Early Childhood, Wills Blog

Masking, Ventilation, & Air Filtration Effectively Reduce Classroom Transmission of COVID

Yesterday I gave a talk for the Arizona Association of School Business Officials about COVID. During the talk I discussed a few evidence-based interventions that lower transmission of COVID in schools, including universal masking, ventilation and air filtration. After the talk, a few of the attendees asked me for the study I was referencing during my talk called SARS-CoV-2 aerosol transmission in schools: the effectiveness of different interventions.

I thought I’d post this blog so everybody could find that study easier. Here are the Results and Conclusions of the study:

Results

The most effective single intervention was natural ventilation through the full opening of six windows all day during the winter (14-fold decrease in cumulative dose), followed by the universal use of surgical face masks (8-fold decrease). In the spring/summer, natural ventilation was only effective (≥ 2-fold decrease) when windows were fully open all day. In the winter, partly opening two windows all day or fully opening six windows at the end of each class was effective as well (≥ 2-fold decrease).

One HEPA filter was as effective as two windows partly open all day during the winter (2.5-fold decrease) while two filters were more effective (4-fold decrease). Combined interventions (i.e., natural ventilation, masks, and HEPA filtration) were the most effective (≥ 30-fold decrease). Combined interventions remained highly effective in the presence of a super-spreader.

Conclusions

Natural ventilation, face masks, and HEPA filtration are effective interventions to reduce SARS-CoV-2 aerosol transmission. These measures should be combined and complemented by additional interventions (e.g., physical distancing, hygiene, testing, contact tracing, and vaccination) to maximize benefit.

Will Humble State Legislature, Wills Blog

Arizona Legislative Session Begins: AzPHA Starts Taking Positions on Bills

We’re off to the races for the 2nd Regular Session of the 55th Legislature.  Over 100 bills have already been pre-filed. So far, there are several repeat themes from the 2021 session on election procedure, school choice, and education issues, and restricting public health and healthcare mandates. We’ve already signed up in opposition to a few of those.

AzPHA will be activating our public health policy committee meetings starting next Friday, January 21. I made the appointments in our member Basecamp. I’ll have more details in next Sunday’s member policy update.

The House Health Committee has some new faces, including Representative Beverly Pingerelli (R-LD21) and former Health Committee member Rep. Pamela Powers Hannley (D-LD9), as well as a new Vice-Chair in Rep. Steve Kaiser (R-LD15). The Senate Health Committee also has one new member in recently appointed Senator Raquel Terán (D-LD30).

Senate Health Committee

Committee Members (5R 3D)

Member Position
Nancy Barto (R) Chairman
Rosanna Gabaldon (D) Member
Sally Ann Gonzales (D) Member
Tyler Pace (R) Vice-Chairman
Wendy Rogers (R) Member
Thomas Shope (R) Member
Raquel Terán (D) Member
Kelly Townsend (R) Member

Senate Health Committee will meet on Wednesdays in SHR1 (time TBD)

Here’s the roster of Senators with their contact information: Senate Member Roster

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House Health Committee

Committee Members (5R 4D)

Member Position
Kelli Butler (D) Member
Joseph Chaplik (R) Member
Alma Hernandez (D) Member
Steve Kaiser (R) Vice-Chairman
Joanne Osborne (R) Chairman
Beverly Pingerelli (R) Member
Pamela Powers Hannley (D) Member
Amish Shah (D) Member
Justin Wilmeth (R) Member

House Health Committee will meet on Mondays in HHR4 (time TBD)

Here’s the roster of House members with their contact information: House Member Roster

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