Post-Sequester Caps Hamper Control of Infectious Diseases: Sen. Harkin

Senator Tom Harkin (D-Iowa), Chairman of the Senate Health, Education, Labor, and Pensions (HELP) Committee and the Appropriations Subcommittee on Labor, Health and Human Services and Education has called for an Omnibus bill providing sufficient resources to all federal agencies involved in the control of Ebola and other infectious diseases in the U.S. and overseas. To pay for this, Harkin calls for the lifting the post-sequester caps that return next year when the Murray-Ryan budget deal expires.

Cap Problem

According to Harkin, the post-sequester caps put the government “on autopilot, hampering the work of the [Centers for Disease Control and Prevention] CDC and agencies on the frontlines of controlling Ebola. We must increase resources for CDC, not just to continue their work in the three countries most affected, but also to ramp up surveillance in the 11 countries surrounding the outbreak.”

More CDCs Needed

Harkin believes that every country needs a CDC and that the U.S. must help them develop their own. To that end, Harkin has championed the National Public Health Institutes (NPHI), which currently helps five countries around the world increase surveillance and laboratory and outbreak response capacity to improve the detection of public health threats. Harkin wants NPHI funding increased to expand the program to all 24 of the countries that wish to participate, including 11 in Africa.

CDC’s Role in NPHI

Through leadership and direct engagement with Ministry of Health officials, CDC and partners help countries develop a strategic plan aligned with public health priorities, determine necessary policy changes, create a sustainability plan, and execute a project which includes linking NPHIs with other established NPHIs or U.S. State Health Departments that can provide additional public health expertise. CDC’s role in NPHI emphasizes: (1) high impact investments to maximize an NPHI’s self-reliance; (2) the leveraging of existing partnerships; and (3) the sharing of scientific expertise through a time-limited engagement of 3 to 5 years.

On the Homefront

According to Sen. Lamar Alexander (R-Tenn.) “we must take the deadly, dangerous threat of Ebola in West Africa as seriously as we take the ISIS threat in the Middle East. The spread of this disease requires a more urgent response from the U.S. and other countries.”Alexander urges President Obama to immediately: (1) begin screening at all U.S. airports any person who is traveling to the U.S. from one of the countries with an Ebola epidemic; and (2) designate a single cabinet member to coordinate the response among the agencies involved and the other countries of the world. The U.S. screening would be in addition to any screening received when they leave the country of outbreak.

Harkin believes that in the U.S. we need to: (1) better train doctors in what to look for; (2) strengthen our quarantine stations at the 20 busiest entry-points to the U.S.; (4) fund basic research for better future treatments; and (4) fund clinical trials for potential vaccines and therapies that are currently in the pipeline now.

Dental Therapists Could Be End to Oral Workforce Decay

By Lisa A. Weder

In a push for states to expand their dental workforce, Families USA has launched its Access to Dental Care Initiative, which focuses on improving awareness of dental care access for low-income families and expanding the use of mid-level providers, such as dental therapists, in more states. The initiative attempts to heed the call of underserved populations in which 14 million low-income children went without dental care in 2011, according to Pew Charitable Trusts (Pew). Pew attributes the workforce problem to an unbalanced distribution of dentists across the country and the small network of dentists who participate in Medicaid. Families USA says this impacts more than 49 million Americans.

The initiative centers on expanding dental teams to include dental therapists in order to reach more patients. Reaching more dental patients allows dentists more time to focus on treating patients with complex care needs.

Families USA sees dental therapists as a means to cost-effective and patient-centered care allowing dental practices to increase productivity and revenue because dental therapists earn lower salaries, take a shorter amount of time to train (receiving two to three years of hands-on training), and are able to provide routine preventive and restorative procedures including dental exams, cleanings, x-rays, fluoride treatments, sealants, fillings, and basic extractions under the general supervision of a dentist. They also provide much needed prevention and education services within communities where dentists are scarce.

Dental therapists already provide care in more than 50 other countries, as well as in previously underserved communities in Alaska and Minnesota. Maine passed legislation in 2014 allowing dental therapists to provide care within dental practices, and 15 other states are considering the move as well.

Three nonprofit dental programs reaped benefits of using dental therapists:

  • People’s Center Health Services, a federally qualified health center (FQHC) in Minnesota, targets Minneapolis’ diverse, low-income population. In April 2012, the FQHC became the first to hire a dental therapist to increase the number of patients who could be served. She saw 1,756 low-income, uninsured patients in the first year.
  • Norton Sound Health Corporation, a tribally owned and operated nonprofit health care organization, deploys dental health aide therapists to distant rural locations. According to Mark Kelso, D.D.S., the group’s dental director, dental therapists who provide routine care have given its dentists more time to attend to unmet needs for higher-level procedures. One dental therapist contributed to saving approximately $95,000 in Medicaid outlays for travel by providing early preventive care and treatment.
  • The Virtual Dental Home is a demonstration project operated by the University of the Pacific School of Dentistry at sites throughout California. The project tests delivery of health-related services and information via telecommunications technologies to provide dental care to populations that would otherwise not receive care. It targets patients in community settings such as elementary schools, Head Start programs, and nursing homes in low-income areas. The dental therapists collect dental information that is sent electronically to a supervising dentist, who creates a treatment plan for the hygienist to implement.

Families USA would like to see more states investigate expanding their oral health workforce to meet the needs of all of their residents, but in particular to meet the needs of underserved children. “Improving children’s oral health will involve many policy and public health changes, and strategies to expand the oral health workforce are a critical component of these changes.”

Highlight on Kentucky: Provider Shortage Spawns Creative Practices in the Bluegrass State

As the nation faces what has been characterized as a primary care shortage, due at least in part to the implementation of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) and the resulting increase of newly insured individuals, some states have acted to offset the provider shortfall. Kentucky, a state which has been reported as lagging behind the primary care physician-to-citizen ratio, is among those states taking at least a creative approach to the looming shortage. While at least one of these practices, which involved stepping up the responsibilities and authority of nurse practitioners, has been widely reported as following the trend of many other states that are working to quell the primary care shortage, another path has been drawn to target other types of underserved patients.

Physician Shortage Nationwide

According to data reported by the Association for American Medical Colleges (AAMC) and the Health Resources and Service Administration (HRSA), the nation overall and especially certain rural areas are beginning to face a severe shortage of health care providers. In sum, the HRSA report highlights the following: (1) almost 20 percent of Americans live in areas that have an insufficient number of primary care physicians and (2) 16 percent of Americans live in areas with insufficient numbers of dentists. Perhaps what is most shocking is the final result that was highlighted in that study that indicated 30 percent of Americans reside in areas where there is a shortage of mental health providers. The AAMC predicts that by 2020 there will shortage of 45,000 primary care physicians and an equal number of needed but non-existent specialists.

Kentucky Shortage

While some reports indicate that these predictions were incorrect or have at least failed to come to fruition as of yet, local sources in Kentucky outlined its provider shortage in no uncertain terms. In particular, this report included data offered by the Kentucky Rural Medical Educators Conference, which asserted that “Kentucky had a 1,287:1 primary care physician-to-citizen ratio, 557 short of the national average.” Additionally, the HRSA data lists Kentucky as among the states with the lowest per capita number of psychologists and mental health counselors.

Targeting Mental Health

While Kentucky has recently passed a law empowering nurse practitioners to prescribe medication, presumably to fill the shortage of primary care providers, it also has adopted a measure to target the shortage of mental health providers. Specifically, through the passage of a new law, Kentucky recently became the sixth state to allow pastoral counselors to become licensed as mental health counselors. According to a local source, the state joined Arkansas, Maine, New Hampshire, North Carolina, and Tennessee to provide this licensing option for pastoral counselors. It appears in doing so, the state officials hoped that this option would encourage increased numbers of pastoral counselors to become mental health counselors and fill the void of mental health care professionals in the state.

As it has been noted in nationwide data, the demand for mental health care professionals, like primary care providers, is expected to grow as more individuals take advantage of coverage options under the ACA. In terms of mental health, the combination of the ACA mental health benefits and the Mental Health Parity and Addiction Equity Act is also projected to increase numbers of potential new patients in this field, creating more demand for providers. Critics of the law have asserted the importance of maintaining differentiation between mental health providers and pastoral counselors, who may be swayed by spiritual factors and are generally thought to be not in the same category as non-pastoral counselors, as reasons for blocking its passage previously. Yet the report also noted that pastoral counselors often serve clients outside of churches and treat patients of different faiths and denominations. Additionally, the training requirements for pastoral counselors are often more stringent than those requirements for certain types of mental health counselors.

Jim Beall: California’s Mental Health Parity Violation ‘Terminator’

Insurers must obey the California mental health parity laws or pay a hefty sum, according to the recently passed California Senate bill (SB) 1046. Senator Jim Beall (D) introduced the consumer-minded bill to address insurance companies’ violations of the parity laws and to give penalty authority to California’s Department of Insurance (DOI), the state’s regulator of self-employer and individual insurance plans, as the Department of Managed Health Care (DMHC), the state’s health plan regulator in February 2014.

A chair of the Senate Mental Health Caucus, Beall said the bill “puts health insurers on the alert that they must live up to the law or face fines’’ of up to $2,500 per day. The existing California law allows the DMHC to levy per-day penalties for on-going mental health parity violations. However, California’s codes do not give the DOI the same authority, and some private insurers are taking advantage. The new law will allow the DOI to impose the fines and close loopholes for insurance companies seeking to escape the parity laws. The DOI handles approximately 10 percent of health care consumers.

Mental health parity also was addressed in the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), which requires that inpatient, outpatient, and emergency mental health services be available to underserved populations. A Final rule (78 FR 12834) issued by HHS in February 2013, implemented the ACA to require Exchanges and insurance issuers to cover mental health and substance use disorder services as one of the 10 essential health benefits (EHB) categories for the individual and small group markets. Section 1302 of the ACA implemented an EHB package that includes coverage requirements, cost-sharing limits, and actuarial value requirements for health plans. This paved the way to 2014 parity requirements, under which all health plans, including those sold through Exchanges or Marketplaces, must offer coverage of mental health services comparable to coverage of medical and surgical benefits. The ACA requirements comply with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), which previously established parity requirements, but did not apply them to health plans without coverage for mental health care or to companies with less than 50 employees.

Other states, such as Washington, have been experiencing similar insurance parity violations, in which blanket exclusions on medically necessary mental-health care services are imposed and left out of policy text.

Beall strives to terminate the loopholes insurers have found and improve access to mental health care. According to Beall, there are approximately 2 million insured Californians who could not get needed mental health services. Beall has championed several health insurance efforts including his creation of the Children’s Health Initiative to provide every child in Santa Clara County with health insurance and his legislation to help foster care children, low-income families, and people with disabilities.

SB 1046 was passed by the state assembly on August 4, 2014, and is awaiting Governor Jerry Brown’s approval.