Critical Health Areas Project (CHAP) Newsletter
Volume 1, Issue 6
October 16, 2006
Announcement
Health & Cultural Competency Web-Assisted Audioconference Series
This FREE web-assisted audioconference series on cultural competency is part of a grant-funded project, the Critical Health Areas Project (CHAP) at the Forum for State Health Policy Leadership, supported by the Robert Wood Johnson Foundation.
Chronic Care and Quality
Pay for Performance Initiatives
Seven states, Arizona, Connecticut, Idaho, Massachusetts, Missouri, Ohio, And West Virginia are participating in an initiative that will help them develop incentive programs for providers of Medicaid service to increased the quality of care that Medicaid beneficiaries receive. This idea of linking payment with the quality of care given and outcomes is know as "Pay for Performance." These seven states will work with the Center for Health Care Strategies which has developed the Pay-for Performance Purchasing Institute to test Medicaid provider pay for performance strategies and performance measures.
In addition to participating in this new initiative, Massachusetts passed law as a part of it's health reform legislation in the 2006 session that links Medicaid payments to improving the quality of care, cost containment, and also reducing racial and ethnic disparities. The quality criteria will begin in July 2007. The state Health and Human Services agency and two outside advisory groups will be developing the criteria.
Resources
Medicare Pay for Performance Initiatives: http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1343
Pay for Performance resources from The Center for Health Care Strategies: http://www.chcs.org/publications3960/publications_show.htm?doc_id=366630
California HealthCare Foundation: http://www.chcf.org/topics/chronicdisease/index.cfm?subtopic=CL503
Information on Massachusetts Universal Health Care Package: http://www.ncsl.org/programs/health/massoverview.htm
Healthcare Access
Indian Health Services and Medicaid
American Indians and Native Alaskans receive health services through the Indian health system. This system includes services provided by the federal Indian Health Service (IHS), tribally operated programs and urban Indian clinics. This system is considered to be “pre-paid,” with a Federal obligation to provide for health care in return for the land ceded in more than 800 treaties and presidential executives orders. As a result, tribal members are not charged for services provided under these programs. Approximately 1.8 million American Indians and Alaska Natives are eligible for these services; of that number, about 1.6 million people are active in the system. The Indian health system has 49 hospitals, 247 health centers, 5 school health centers, 309 health stations, and 34 urban health clinics.
The federal government also fully funds Medicaid benefits provided through IHS facilities, with a federal match of 100%. States are not required to contribute any share to this Medicaid program. States, however, are required pay the usual share for Medicaid services in urban Indian clinics as well as Medicaid services referred by the IHS to private providers.
While on the surface this system appears to address the needs of the American Indian and Native Alaskan population, this system has a number of flaws. The mismatch between funding and need manifests in the worst health of any group in most comparisons.
Many American Indians and Native Alaskans face barriers to accessing public health insurance, such as lack of transportation, not having the proper identification documents, as well as social and culture barriers. Many tribal members eligible for Medicaid do not apply because they assume that the federal government is obligated to provide health care funding. Both tribal members and non-tribal member Medicaid outreach counselors also presume that public assistance is unnecessary because the federal government is obligated to provide health care for tribal members.
The federal government has perennially underfunded the IHS. The IHS is not a federal entitlement program, and federal funding levels are set each year at the discretion of Congress. Current funding levels meet approximately 60 percent of IHS need. Moreover, most IHS funding is sent to reservation clinics and hospitals despite the fact that about 60 percent of Natives live off the reservation. Medicaid funding cutbacks could result in cost-sharing or a reduction in IHS services and further hurt access to care for American Indians and Native Alaskans.
In 2005, the Montana legislature passed HB 452, which requires Montana’s Dept. of HHS to seek a federal waiver so that any reductions in Medicaid eligibility do not shift costs to IHS facilities and to seek to leverage federal financial participation through the state children’s health insurance program and Medicaid. In addition, this law requires joint cooperation between the state and tribal members to improve Medicaid outreach and enrollment.
Additional resources:
Addiction Prevention and Treatment
CALIFORNIA COURT BLOCKS CHANGES IN DRUG TREATMENT LAW
Legislation that would have put more teeth into California’s drug court system has been temporarily blocked by a lawsuit.
Signed into law in July, the legislation (SB 1137) amends Proposition 36, a ballot initiative passed by California voters in 2001. Also known as the Substance Abuse and Crime Prevention Act of 2000, Prop. 36 allows nonviolent drug offenders to choose treatment as an alternative to jail.
The new law would amend Prop. 36 by adding “flash incarcerations” as punishment for those not adhering to the program. This would allow judges to impose short jail sentences—ranging from two to five days—on offenders who violate treatment. The bill also provides increased funding for the program, as well as increased judicial supervision of clients.
Superior Court Judge Winifred Smith ruled that the legislative changes are at odds with the original purpose of the law. The court issued a preliminary injunction blocking implementation of SB 1137, saying it would create “a probability of harm to the public, both in terms of expenditures that Proposition 36 apparently meant to prevent, and in terms of potential incarceration of persons that Proposition 36 apparently meant to avoid.” The court also expressed concern that the will of the voters was ignored, supporting the plaintiffs’ argument that only another initiative could legally amend the original law.
Under Prop. 36, offenders in treatment must report to a probation officer, a case manager and a treatment officer. If treatment is completed, the court may expunge the charges. A violation such as testing positive or missing a meeting can result in arrest and being sent back to court. Three violations means an offender must serve out his or her jail term.
SUPREME COURT HEARS CASE ON DEPORTING IMMIGRANTS
In one of its first cases of the new term, the Supreme Court heard an argument by the Bush administration that legal immigrants can be deported for state-level drug felonies. The argument goes back to a 1996 immigration law that requires deportation of non-citizens who commit an “aggravated felony.” This includes any drug-trafficking offense considered a felony under federal law. Lawyers for the administration are arguing that deportation should apply to state-level felony convictions for drug possession.
The transcript of the oral arguments for Lopez vs. Gonzalez can be found at http://www.supremecourtus.gov/oral_arguments/argument_transcripts/05-547.pdf
OHIO BEGINS PRESCRIPTION MONITORING
On October 2nd, the Ohio State Board of Pharmacy launched the Ohio Automated Rx Reporting System, a computer database that tracks sales of controlled substances. The goal is to prevent “doctor shopping,” wherein patients visit multiple doctors in order to get multiple prescriptions of a drug. The Board will require bi-monthly reports of prescription sales from retail and mail-order pharmacies that sell to Ohio patients. Doctors and pharmacists will then have access to reports on the Internet that show if a patient has been doctor shopping. The general public will not have access. Ohio becomes the 25th state with a monitoring program. "A doctor can look at the report and see that you've been going to one doctor and one pharmacy and you're a legitimate patient. But if he sees you going to 15 different doctors and 15 different pharmacies and you've been going the next day and then the next day and the next day, they see you might not be a legitimate patient and might not want to write a prescription for you,” William Winsley, executive director of the pharmacy board, told the Cleveland Plain Dealer.
DRUG ABUSE BOTH UP AND DOWN IN CALIFORNIA
A survey of California students shows that more kids are abusing prescription drugs, even as use of other substances is decreasing. The survey found that 15 percent of 11th graders and 9 percent of 9th graders use pharmaceuticals without a prescription. Prescription drugs are now the 3rd most popular drugs of choice in the state among youth, trailing alcohol and marijuana. On the upside, the survey found a significant decrease in underage drinking and use of marijuana and inhalants. In the decade since the last survey, drinking among 9th graders dropped from 60 percent to 40 percent, while drinking among 11th graders fell from 70 percent to less than 50 percent. However, heavy drinking among these same groups did not change.
Providers and Workforce
Mandating Cultural Competency Education
Faced with growing minority populations and evidence of dramatic racial and ethnic health disparities, a number of states have been mandating that cultural competency training be a part of medical education. In 2005, five states (Arizona, California, Illinois, New Jersey and New York) considered such bills; New Jersey’s was the first to become law. In spring 2006, more states debated similar legislation, and California and Washington were added to the list of those with mandates.
States vary in terms of who is responsible for these requirements. California puts the burden on medical education institutions—courses must contain curriculum pertaining to cultural and linguistic competence. Similarly, Washington mandates that health professionals’ educational programs include a course on multicultural health. However, Washington prohibits entities from denying an applicant a health profession credential because the applicant completed an educational program that did not include a multicultural health component. New Jersey, on the other hand, considers cultural competency to be the responsibility of doctors. The Garden States requires physicians to receive cultural competency training before they can obtain a state medical license or be re-licensed.
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