Arizona Averages Over 25 Opioid Overdoses Per Day

An Arizona Republic article and the Arizona Department of Health Services Director's blog, Dr. Cara Christ, brings the opioid crisis home (1,2). Christ states that over 3200 opioid overdoses with over 400 deaths occurred between June 15 and October 17 in Arizona. This averages to over 25 overdoses and 3 deaths per day.

Some of the data from Christ’s blog are below:

• Males 25-29 have the highest rates of suspected opioid overdoses.
• 37% of people experiencing a suspected opioid overdose had an opioid prescription in the two months prior to their overdose.
• The majority of overdoses occur at home.
• The most commonly cited pre-existing health conditions of those with suspected overdoses was chronic pain. Depression and other behavioral health conditions were also common health conditions noted.
• Meth and heroin were the most frequently cited drugs involved in reported neonatal abstinence syndrome.
• About 40% of people experiencing suspected opioid overdoses who had a prescription in the Controlled Substances Prescription Monitoring Program had been prescribed both benzodiazepines and opioids in 2017. When these medications are combined, it is so dangerous that the FDA gives it a “black box” warning.
• About 40% of people experiencing a suspected overdose that had prescription history in the Controlled Substances Prescription Monitoring Program (CSPMP) had received opioid prescriptions from 10 or more providers.
• Only about 25% of clinicians prescribing controlled substances checked the CSPMP prior to prescribing.

On October 16, a new mandate went into effect that requires clinicians to check the CSPMP prior to prescribing an opioid or benzodiazepine. Other states implementing such mandates have experienced reductions in people with 4 or more prescribers or pharmacies, reductions in opioid prescribing, and reductions in Morphine Milligram Equivalent daily doses.

The CSPMP requires registration and login but is relatively easy to use (3). You can search not only in Arizona but other states as well. Personally, as a pulmonary consultant I infrequently prescribe opioids or benzodiazepines. However, I have used the website once to check a benzodiazepam prescription for a patient I suspect might be addicted. No other prescriptions were found. It at least gave me some assurance that he was not obtaining prescriptions from multiple practioners while we attempt to wean him off this medication.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. McCrory C. More than 400 opioid-overdose deaths reported in Arizona since June 15. Arizona Republic. October 27, 2017. Available at: http://www.azcentral.com/story/news/local/arizona/2017/10/27/more-than-400-opioid-overdose-deaths-reported-arizona-since-june-15/809157001/ (accessed 10/28/17).
2. Christ CM. Opioid update: latest data and emergency rules update. October 17, 2017. Available at: http://directorsblog.health.azdhs.gov/opioid-update-latest-data-and-emergency-rules-update/ (accessed 10/28/17).
3. Arizona Board of Pharmacy. Arizona PMP Aware. Available at: https://pharmacypmp.az.gov/ (accessed 10/28/17).

Cite as: Robbins RA. Arizona averages over 25 opioid overdoses per day. Southwest J Pulm Crit Care. 2017;15(4):179-80. doi: https://doi.org/10.13175/swjpcc133-17 PDF 

Maryvale Hospital to Close

Abrazo Health Care has announced that it intends to close Maryvale Hospital effective December 18, 2017. Maryvale Hospital has had declining admissions and was realigned as a satellite facility of Abrazo West Campus in Goodyear in May 2017. Abrazo said they hoped to place most of the 300 Maryvale employees at other Abrazo medical centers.

Richard A. Robbins, MD

Editor, SWJPCC

Cite as: Robbins RA. Maryvale hospital to close. Southwest J Pulm Crit Care. 2017;15(4):164. doi: https://doi.org/10.13175/swjpcc129-17 PDF 

California Enacts Drug Pricing Transparency Bill

The Mercury News is reporting that California governor Jerry Brown signed a bill Monday making drug pricing more transparent (1). The legislation requires pharmaceutical companies to notify health insurers and government health plans at least 60 days before making price hikes and explain the reason for the increase. The pharmaceutical industry had lobbied hard against the measure, worried that it could become a national model and the first big step toward price controls. “The essence of this bill is pretty simple,” Brown told a room filled with supporters of Senate Bill 17. “Californians have a right to know why their medical costs are out of control, especially when the pharmaceutical profits are soaring. That’s the take-away message.”

“It is disappointing that Gov. Brown has decided to sign a bill that is based on misleading rhetoric instead of what’s in the best interest of patients,” said Priscilla VanderVeer, spokeswoman for the Washington, D.C.-based Pharmaceutical Research and Manufacturers of America. She added that there is “no evidence that SB 17 will lower drug costs for patients.”

The bill does not actually control drug prices, leading some critics to suggest it is toothless. However, the bill’s backers say that transparency in other health care sectors has been successful in reducing costs. Anthony Wright, executive director of Health Access California, agreed. He said the advance notice and information required under SB 17 “is invaluable” to large health care purchasers such as insurers, union trusts and employers, and would enable them to drive a better deal for consumers.

Brown also signed a related bill on Monday. Assembly Bill 265 will prohibit prescription drug manufacturers from offering discounts for name-brand drugs, if a less-expensive equivalent brand is available, preventing the use of higher-priced drugs when unnecessary.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Seipel T. Gov. Brown signs drug pricing transparency bill. The Mercury News. October 8, 2017 (updated October 9). Available at: http://www.mercurynews.com/2017/10/08/gov-brown-to-sign-drug-price-transparency-bill/ (accessed 8/10/17).

Cite as: Robbins RA. California enacts drug pricing trasparency bill. Southwest J Pulm Crit Care. 2017;15(4):159. doi: https://doi.org/10.13175/swjpcc122-17 PDF 

Senate Health Bill Lacks 50 Votes Needed to Proceed

Yesterday (7/17), two additional Senators – Sen. Roberts (R-KS) and Sen. Lee (R-NE) joined Senators Paul (R-KY) and Collins (R-ME) in announcing their intention to vote “no” on the motion to proceed on considering the Senate ACA repeal and replace legislation – effectively blocking Senate consideration of the current Senate Republican health care bill. Senators Paul, Lee and Roberts opposed the bill for not going far enough, while Senator Collins expressed her concern the bill goes too far.

With the 4 publicly announced NO votes – Senator Majority Leader Mitch McConnell does not have the 50 votes needed to begin debate on the bill, let alone assure final passage.

Speculation now turns to what happens next. President Trump has tweeted his preference to let Obamacare fail as a way to force Democrats to negotiate new legislation. Senator McConnell has suggested a series of symbolic votes on full repeal with multi-year delay to work on a replacement plan or voting on the House passed bill. However, three moderate senators, Capito (R-WV), Collins (R-ME) and Murkowski (R-AK), announced today they will not support procedural votes on an immediate ACA repeal bill.  Alternatively, Congress may abandon the health reform effort for the time being and pivot to other legislative priorities (tax reform and infrastructure). The failure of McConnell to lead the Senate effort may clear the way for a bipartisan effort to address the shortfalls of the ACA.

Please keep in mind the House repeal and replace effort “died” before the House ultimately passed its repeal legislation, so while the Senate effort looks to be “permanently stalled” it is probably premature to call it “dead.”

Nuala S. Moore

American Thoracic Society

Washington, DC USA

Cite as: Moore NS. Senate health bill lacks 50 votes needed to proceed. Southwest J Pulm Crit Care. 2017;15(1):45. doi: https://doi.org/10.13175/swjpcc093-17 PDF 

Medi-Cal Blamed for Poor Care in Lawsuit

Several sources are reporting a lawsuit filed in California alleging poor care in the state’s Medicaid program, Medi-Cal (1). The suit alleges that Medi-Cal failed to pay doctors enough to provide proper care. The suit was filed by five Latino residents on behalf of California’s 13 million lower-income residents, more than half of them Latinos. The suit alleges that "…California has created a separate and unequal system of health care, one for the insurance program with the largest proportion of Latinos (Medi-Cal), and one for the other principal insurance plans, whose recipients are disproportionately white.”

The state budget includes $107 billion in state and federal funding for Medi-Cal this year, but the spending is not enough to restore reimbursement cuts made during the Great Recession of 2008. A proposal in the U.S. Senate to repeal the Affordable Health Care law (ACA, Obamacare) could drastically reduce funding for Medicare and the individuals who can access it.

Thomas Saenz, an attorney with the Mexican American Legal Defense and Educational Fund who filed the lawsuit, said he believes it is the first time the civil rights approach has been tried in California. According to Saenz this legal approach is possible because California is one of the few states to specifically prohibit discriminatory effects in state programs.

Other states in the Southwest also have disproportionately large Hispanic populations in their Medicaid programs (Table 1).

Table 1. Percent Caucasian and Hispanic total population/Medicare population by State (2,3).

Reimbursement does appear disproportionately low in California which ranked 48th in the nation in 2015 in how much it paid hospitals, doctors and other healthcare providers for treating Medi-Cal patients, according to the Kaiser Family Foundation (4). In the Southwest the state with the highest reimbursement was Nevada (5-10). California reimbursement averaged only 47% of Nevada reimbursement for the procedures listed (Table 2).

Table 2. Medicare reimbursement for common procedures by state (4-9).

The reason for the wide differences in reimbursement rates is unclear but is likely historical dating back to cost containment programs from the 1980’s and 90’s (11). The differences do not appear to be explained by differing costs of living. None of the procedure reimbursements correlated with the cost of living in the largest city in each state (Phoenix, Los Angeles, Denver, Albuquerque, Honolulu, and Las Vegas, p>0.1, all comparisons).

The chances of the lawsuit’s success are unclear since there is no precedent. However, it seems likely that if the suit is successful, more suits will be filed since California Medi-Cal’s situation of disproportionately providing care to minorities is not unique.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Thompson D. Latino plaintiffs sue California alleging poor health care. Associated Press. July 12, 2017. Available at: http://abcnews.go.com/Health/wireStory/latino-plaintiffs-sue-california-alleging-poor-health-care-48592841 (accessed 7/13/17).
2. Kaiser Family Foundation. Population distribution by race/ethnicity. 2015. Available at: http://www.kff.org/other/state-indicator/distribution-by-raceethnicity/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D (accessed 7/13/17).
3. Kaiser Family Foundation. Distribution of the nonelderly with Medicaid by race/ethnicity. 2015. Available at: http://www.kff.org/medicaid/state-indicator/distribution-by-raceethnicity-4/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D (accessed 7/13/17).
4. Dickson V. Low Medi-Cal payments could weaken expanded coverage for undocumented children. Modern Healthcare. June 17, 2015. Available at: http://www.modernhealthcare.com/article/20150617/NEWS/150619908 (accessed 7/13/17).
5. California Department of Health Care Services Medi-Cal. Medi-Cal Rates. June 15, 2017. Available at: https://files.medi-cal.ca.gov/pubsdoco/rates/rateshome.asp (accessed 7/13/17).
6. Arizona Health Cost Containment System. Physician fee schedules. 2017. Available at: https://www.azahcccs.gov/PlansProviders/RatesAndBilling/FFS/Physicianrates/ (accessed 7/13/17).
7. Colorado Department of Health Care Policy and Financing. Provider rates & fee schedule. June 2017. Available at: https://www.colorado.gov/pacific/hcpf/provider-rates-fee-schedule (accessed 7/13/17).
8. Quest Hawai’i. Medicaid fee schedule. 2013. Available at: http://www.med-quest.us/ (accessed 7/13/17).
9. Nevada Division of Health Care Financing and Policy. Fee schedules. Available at: http://dhcfp.nv.gov/Resources/Rates/FeeSchedules/ (accessed 7/13/17).
10. New Mexico Human Services Department. New Mexico Medicaid fee for service CPT code fee schedule. 2017. Available at: http://www.hsd.state.nm.us/uploads/FileLinks/e7cfb008157f422597cccdc11d2034f0/7.17_CPT_Codes__2_.pdf (accessed 7/13/17).
11. Tatar M, Paradise J, Grafield R. Medi-Cal managed care: an overview and key issues. Kaiser Family Foundation. Mar 02, 2016. Available at: http://www.kff.org/report-section/medi-cal-managed-care-an-overview-and-key-issues-issue-brief/ (accessed 7/13/17).

Cite as: Robbins RA. Medi-Cal blamed for poor care in lawsuit. Southwest J Pulm Crit Care. 2017;15(1):42-4. doi: https://doi.org/10.13175/swjpcc091-17 PDF