Double Your Signing Bonus, Double Your . . . Prison Dentists?
If the prospect of polishing prisoner teeth is not tantalizing enough to get more dentists at the Michigan Department of Corrections, the state is now looking to sweeten the deal by doubling the bonus money available for new hires.

Dentists hired for state prisons have been allowed a $5,000 bonus for several years now, but the DOC is now seeking approval for an additional $5,000 to be available once dentists complete their initial one-year probationary periods, meaning they can earn an extra $10,000 within the first year of employment.

DOC spokesperson Holly Kramer said the bonuses would be funded out of existing appropriations. And, in addition to the bonuses, prison dentists remain eligible for a 5 percent performance bonus each year.

“While it’s still a challenge for us to compete with private sector pay rates, these are good careers within the MDOC and we are hoping this might provide some incentive,” Kramer said.

The DOC has been trying to attract more dentists, and seeking additional incentive money from the Michigan Civil Service Commission was one way to do it.

The move to allow the additional $5,000 bonus, which was also requested by the Michigan Department of Health and Human Services, was scheduled for consideration in mid-December.

The DOC has made the case to lawmakers that it has struggled to attract more dentists because of Civil Service constraints on what dentists can be paid.

According to the DOC, the current maximum hourly rate for a Civil Service dentist is $60.51. However, if the state’s benefit package is factored in, that bumps it to $113.41. However, the DOC indicated the total contractual hourly rate the state is being asked to pay temporary contract workers is $140.

That’s one reason why the DOC is facing a prison health care worker shortage, a topic of conversation at a recent House Corrections Appropriations Subcommittee meeting.

As for the DHHS, spokesman Bob Wheaton said he knows the department has had trouble recruiting dentists in the past for its psychiatric facilities.

He said the department has permanent intermittent dentists at the Caro Center that essentially split the duties, meaning they are allowed to work part-time, so that one may cover 45 hours in a pay period and the other 35, for example, Wheaton said.

The DHHS also has one at the Center for Forensic Psychiatry that is part-time and a full-time dentist at Kalamazoo Psychiatric Hospital.

CON Scale-Back Bills Rolled Out To Mixed Reviews
Small rural hospitals, some psychiatric facilities, air ambulances and outpatient cardiac procedures wouldn’t need to go through the additional state regulatory step known as Certificate of Need under legislation receiving its first hearing Dec.5.

The bills championed by Senate Health Policy Chair Curt VanderWall (R-Ludington) also exempts capital expenditures from the oversight of the 11-member CON Commission, which would be expanded to include two public members under the package.

VanderWall unveiled the bills in early December after more than 80 meetings with health care-related groups. The proposed reforms come after VanderWall saw Northern Michigan hospitals move certain services to larger campuses to cut costs among other bothersome health care trends.

No specific interest group had a hand in crafting all seven bills, VanderWall said. This project is something he began last term as a freshman House member and something he said he’s willing to add to and subtract from to “provide better quality care, improve access and reduce costs.”

“This is a huge paradigm shift, I understand,” he said. “But let’s talk about the issues. I understand people are pretty nervous, but we’ll have to work through that.”

CON is the state oversight system designed to limit the proliferation of large-dollar equipment and facilities to prevent an oversaturation that could add costs to health care and leave poorer areas without access to critical services.

The Commission basically prevents boutique medical operations from skimming away the well-insured patients in affluent areas to the detriment of everyone else.

The Michigan Health and Hospital Association, Blue Cross Blue Shield of Michigan, Michigan Manufacturers Association and CON Chair James “Chip” Falahee Jr., representing Bronson Hospital, all came out in general support of the CON system and had mixed opinions on the bills.

By and large, they liked expanding the CON to 13. They were not convinced that unplugging psychiatric services from CON would improve access. A lack of psychiatrists and mental health professionals, in general, is the larger issue, they said.

Instead of taking capital expenditures out of the CON process, they suggested increasing the dollar trigger before the Commission would become involved. Currently, anything more than $3.325 million gets flagged for review. Perhaps that amount could be increased.

VanderWall said he was bothered that a local hospital wanted to add a reasonable rehabilitation center to its facility, but was forced to pay thousands of dollars in CON permitting fees to make it happen.

Those testifying weren’t crazy about removing cardiac procedures from the CON process either. An MHA memo given to committee members noted that in 1 percent of the cases involving heart procedures, there is a major complication that requires emergency intervention.

The clear message in committee was that those going an outpatient route for a new pacemaker don’t want to be one of those 1percent.

A 2007 study by Rice University’s James Baker III Institute for Public Policy found 103 cardiac patients’ deaths could have been avoided by retaining CON rules.

Blue Cross Blue Shield of Michigan’s Amy McKenzie said she can understand lowering CON thresholds for rural hospitals, but carving them out of the process entirely isn’t the answer.

Without CON, the concern is that large for-profits will lease out equipment, run it out of a small rural hospital and offer high-margin, profitable services through the type of cherry-picking CON is designed to prevent.

“New services without demonstrated need simply divert services, and may financially cripple an existing, well-performing provider that offers the full spectrum of services, ultimately resulting in less choice and access for the community,” McKenzie said.

The bills are supported by the Americans for Prosperity AFP, but VanderWall said the free-market advocacy group was not involved in crafting the bills. Also, while Senate Majority Leader Mike Shirkey (R-Clarklake) is aware of the legislation, he’s “left me alone on this,” VanderWall said.

The goal is to hold another hearing on the bills next week and then possibly make changes over the holiday recess, he said.

“The bills introduced today are commonsense reforms that will eliminate unnecessary red tape, reduce costs and provide more access to Michigan residents,” he said.

Drugs From Canada Bill Faces Tough Questions In Health Policy
Legislation allowing the importation of prescription medications to Michigan, as a way to shave prices, ran into a series of tough questions and criticisms Dec. 5 in the House Health Policy Committee.

For one, if the state set up a program to import meds from Canada, would the Canadian government ban exports, asked Rep. James Lower (R-Eureka Twp).

John Adams, chair of Canada’s Best Medicines Coalition, said the prime minister, in response to proposals from the Trump administration to do the same thing at the federal level, has already said he would.

“The answer to your question is yes,” Adams told the committee.

Rep. Tommy Brann’s (R-Wyoming) HB 4978 would give the Department of Health and Human Services the responsibility of setting up a program to import medicine wholesale from Canada.

A companion bill, Rep. Steven Johnson’s (R-Wayland) HB 4979, would allow importation from other countries if they can meet federal safety standards. No others do right now.

Brann told of meeting a mother of three while he was going door-to-door in his district.

“Their kids all had Type 1 diabetes,” Brann said. “Medicaid no longer covered insulin for children. A one-month supply of insulin is $606 for one child. She went to Canada for a one-year supply of insulin, saving her family $6,500.”

Brann said three states have passed similar laws, and 17 have introduced similar bills. He said the state DHHS would set up the program, and pharmacies and wholesalers in the state would do the importing.

“The patient will be able to go directly to the pharmacist to get the drug. There will no longer be any need for my constituent to go over to Canada, because she can get that drug right at home,” Brann said.

But Shabbir Imber Safdar of the Partnership for Safe Medicines explained that any program set up by the state, as well as any federal effort to allow Canadian imports, will have to follow the 2003 Medicare Modernization Act.

“One of the most important details of that is that you cannot import biologic drugs,” Safdar told the committee. “So, to the powerful example that is heart-wrenching of diabetics having difficulty affording insulin that is cheaper in Canada, insulin will not be importable under this bill or under the federal regulations. That’s an important thing. If our goal is to address the cost of insulin, this is not the way to do it.”

Other problems he noted with the bill is that Michigan has no authority to inspect pharmacies in Canada and cannot sanction them if it is found they are selling unsafe or counterfeit medicines. Nor could it extradite a violator. Safdar noted one case in which U.S. authorities sought for four years unsuccessfully to extradite a wholesaler who was selling counterfeit cancer medications into the U.S.

Adams contended another problem with the proposal “starts with arithmetic.”

“Our nation of 38 million people does not have the pharmaceutical supply for your 329 million citizens. We are already experiencing shortages. Our health regulator, Health Canada, has reported that at any given time there are up to 2,000 medications in short supply. Let me note that is 2,000 out of 13,000 approved medications.”

That is why he made the trip from Toronto to Lansing to express his concerns about the bills.

“In Canada, we really appreciate America’s bold sense of confidence and pride in self-reliance. I emphasize self-reliance,” Adams said. “That’s why it is disconcerting to witness politicians from both parties looking to my country to make your medicines more affordable. We would love to help if we could, but we cannot.”

Indeed, other state lawmakers have made similar proposals. Rep. Darrin Camilleri (D-Brownstown Twp.) has introduced similar legislation in the House and Sen. Ruth Johnson (R-Holly) has introduced similar legislation in the Senate.

Don Bell, also of the Partnership for Safe Medicines, said Canada does not have enough legitimate prescription drugs to supply the United States. Canada is a ninth the size of the United States and its supply is designed for its own population. That could create additional problems.

“In balance, our genuine supply and the demand created by importation would create a lucrative market that would be ideal for criminals to step in and begin transshipping adulterated, substandard or counterfeit drugs to Michigan, sourced from anywhere but Canada,” Bell said.

That criminal network supplying bad medicines already exists, Bell said. A crackdown discovered illicit 3,000 drug shipments destined for Canada.

The bills do have supporters.

Johnson argued that people today can buy things from all over the world, with one exception — prescription drugs. He contended allowing importation would put “downward pressure on prices and upward pressure on quality.”

He noted the No. 1 reason why people file bankruptcies is medical bills.

Melissa Seifert and Paula Cunningham of the AARP spoke in support of the bills.

“We know that one in three Michiganders is not taking the prescription medications they need because it costs too much,” Seifert said. She contended drugs in Canada are on average 30 percent cheaper.

Safdar said other states have addressed the high cost of prescription drugs and have brought down prices through other programs.

If the cost driver in a given state is just one or a few drugs, it should look to the Louisiana model, Safdar suggested.

New drugs are available for hepatitis C, but they are expensive. Louisiana held a “reverse auction,” asking drug makers what the price would be for them to supply all the drugs needed for the state’s Medicaid patients. But if the number of patients went up, the price would remain the same while the maker would supply whatever amount was needed.

It worked well. Louisiana found it could treat one-third more people for the same amount of money, Safdar said.

“If what is driving your state budget costs for pharmaceuticals appears to be markups from middlemen across the board, then you have a PBM problem, most assuredly, a pharmacy benefit manager problem,” Safdar told MIRS after the hearing.

West Virginia “kicked out” the PBM there and replaced it with people from a local pharmacy school. The state saved $52 million in the first year, Safdar said.

“Pharmacy Benefit Managers are in all of the supply chains, private health insurance and everything else. If you were to make sure their rebates get passed through all the way to the patient, you would see price drops, for sure,” he said.

Genesee County’s Extended Tobacco Sales Ban Thrown Out In Court
Genesee County and its health department cannot enforce its “Tobacco 21” ordinance, which prohibited sales to anyone age 18 to 20, the Michigan Court of Appeals ruled Dec. 4.

In May 2017, the county became the first in Michigan to pass a regulation prohibiting the sale of any tobacco product or paraphernalia to anyone under age 21, and it required a retailer of tobacco products or paraphernalia to place a sign stating such. The ordinance did not prohibit, however, someone 18-20 from using tobacco products in the county.

RPF Oil Company in Grand Blanc filed a lawsuit in Genesee County Circuit, challenging the “Tobacco 21” regulation, alleging it conflicted with the Age of Majority Act and the Youth Tobacco Act.

In June 2017, Genesee County Circuit Judge Judith Fullerton ruled against “Tobacco 21,” saying it is unenforceable.

The county appealed, but in a published opinion the appeals court unanimously affirmed, saying the county’s policy “plainly prohibits what Michigan law permits by diminishing the rights and privileges granted by state law to persons who have reached the age of majority”—defined as 18 years old.

DHHS Head: ‘High Likelihood’ Court Will Block Work Requirements
The head of the Michigan Department of Health and Human Services said Dec. 4 he believes there is a “high likelihood” a court will block implementation of work requirements for Healthy Michigan, resulting in a “huge waste of taxpayer dollars.”

Gov. Gretchen Whitmer formally asked the Legislature to delay the work requirements scheduled to take effect in 2020 for the Healthy Michigan Medicaid expansion program. She got her answer the same day from the GOP legislative leaders: No.

Asked what the administration’s next move is, DHHS Director Robert Gordon said the agency is still bound to issue letters to people outlining how they must comply, despite the fact that “we think there is a . . . high likelihood that a court will block” implementation in Michigan.

If that happens, it will mean sending out more letters, he said, and “at a time when we all ought to agree on using money as well as we can, it would be a huge waste of taxpayer dollars.”

Whitmer’s office said Tuesday it will cost $1 million to issue the letters to 200,000 people, and that DHHS has already spent $28 million to implement work requirements and is on track to spend $40 million more.

Gordon said the federal appellate judges in the D.C. circuit court that presided over oral arguments regarding a work requirements case “indicated a high level of skepticism that work requirements are legal.”

A number of groups recently filed suit in federal district court in D.C. challenging Michigan’s proposed work requirements for Healthy Michigan.

Whitmer has said the work requirements would result in needy families losing their health care, and Senate Majority Leader Mike Shirkey (R-Clarklake) has said Medicaid work rules will actually make those recipients healthier.

At her roundtable the other day, as Whitmer was calling on Shirkey to hit the pause button on his plan to require 80 hours of work monthly or related endeavors to keep health care coverage, the Governor was asked about what was motivating Shirkey.

Her response came one day before the Senator hit the go and not the pause button.

“It’s very clear that this is not about promoting work . . . This is just punitive and about taking away healthcare,” she said.

“I don’t know how the jump was made from embracing one to embracing the other. I can’t explain what’s going on in Sen. Shirkey’s mind, but the ramifications are a lot of people are going to lose health care,” she said.

The next day in his scrum with reporters on the Senate floor, Shirkey said the object was not to remove persons from the rolls but to get them into some job or work training program. In the long run, that would promote good health for them, he said.

Asked if he thought getting a job was more important than having healthcare, he said, “Not at all. I’ve concluded that in life and having something to live for is by all measures, dozens of studies, that it’s one of the best things you can do for your health.”

Asked if he wanted to remove some recipients from the rolls, he said if that happens it will actually help to maintain health coverage for others.

He said there’s a poison pill buried in the original Medicaid expansion plan that says if the costs exceed the savings, the program is terminated.

Hence, Shirkey said, “my hope is that we create enough churn to keep that from happening so that the cost and savings curves don’t cross . . . I want to keep it (the coverage) in place.”

Second Vaping-Related Lung Injury Death Reported In State
A second death has occurred in Michigan associated with a vaping-related lung injury, the Department of Health and Human Services announced Nov. 27.

The vaping fluid involved was tetrahydrocannabinol (THC), according to DHHS spokesperson Bob Wheaton, but it is unknown if the fluid included vitamin E acetate which is a common additive in THC vapes.

Since August, 56 vaping-related lung injury cases have been reported in Michigan, all in the Lower Peninsula. Most have had to be hospitalized for severe respiratory illness. The age range of the patients is 15 to 67.

Outcomes for patients vary, Wheaton said. In one case, the injury was so severe as to require a lung transplant. Others recover quickly while some need intensive care and rehabilitation. The medical community is unsure of the long-term consequences of lung-injury cases, Wheaton said.

As of Nov. 20, 2,290 cases of vaping-related lung injury have been identified in 49 states (all but Alaska) as well as the District of Columbia and two territories. That number includes 47 deaths in 25 states, but the count does not include this second death in Michigan. Reported cases have included mixtures of THC and nicotine as well as THC only and nicotine only vapes.

“We are deeply saddened to announce a second death associated with this outbreak,” said Joneigh Khaldun, chief medical executive and chief deputy for health for MDHHS. “We are urging people to refrain from vaping until the specific cause of the vaping-related severe lung injuries being reported nationwide has been identified. To help with this investigation, we are reminding health care providers to report patients that may have this condition to their local health department.”

DHHS stated it is working with the CDC and the federal Food and Drug Administration to identify the ingredients in the vaping products that is making people sick. So far, no specific brand of device or e-liquid has been identified. The CDC has identified vitamin E acetate as a chemical of concern among people with vaping-related lung injury.

DHHS advises e-cigarette or vape users to immediately seek medical attention if they develop symptoms such as shortness of breath, chest pain, cough, fever or nausea and vomiting.

The department is also urging people to avoid vaping products with THC. Since the specific compounds or ingredients causing lung injury are not yet known, while the investigation continues, individuals should consider refraining from use of all e-cigarette or vaping products, DHHS states.

Lansing Lines is presented in cooperation with MIRS, a Lansing-based news and information service.