By: Jorgen Schlemeier
The Missouri Legislative Session concluded and we accomplished what you sent us to do. First do no harm ring a bell? Well it ain’t just for doctors anymore, we lobbyist also believe in that oath and defeating harmful legislation, or agency rules (both are laws when enacted), have become weighted nearly equal to new initiatives. In the event you do not get to the bottom of this article, I want to give a special thanks to Drs. Doug Char and Jonathan Heidt, who had to endure my continuous questions and request for quick feedback; and Jeff Howell of the Missouri State Medical Association (MSMA) for being very helpful on all of our issues.
Don’t read the newspaper, and definitely not the internet, about what happened in the MLS (Missouri Legislative Session – for the novices and apologies to the veterans), this column has been deemed the official MLS report for this newsletter, sort of.
Nevertheless, short read for the overview. Here you go.
Transportation: Funding passed Senate, died in the House. House has different idea on funding mechanism.
Senate Joint Resolution 39: (constitutional amendment) purported to protect those who refused services to gay couples. Several attorneys in the building disagreed and believed it reached far beyond that interpretation. It was killed in a House Committee after the senate busted a record-breaking 40-hour filibuster with a procedural motion to force a vote.
Guns: If you love them you will love the law that allows statewide carry conceal with a lifetime permit and decriminalizes the act of carrying a concealed weapon onto private property where the owner has posted prohibition signs. The offender can be escorted off property and fined, but no more.
Labor: Paycheck Protection, a bill that would disallow labor organizations from automatically deducting union dues from a workers paycheck, was passed, vetoed and then fell one vote short in the Senate to override the Governor.
Back to Emergency Physician issues…
First, the Budget passed, as it does every year despite the claims I hear from those who do not believe in historical precedent. The budget included $2M for the Regional Care Coordination. The Governor has signed the budget and approved this item. Implementing this will be a heavy lift.
TCD – ED Physician Education Requirements
A long, long, long time ago, when Star Wars was still popular, the Department of Health promulgated rules that placed too onerous education requirements on ED Physicians in order for their respective hospital to meet TCD designations. We worked with the Department and while they attempted to be accommodating, we could not get a substantive change to their education requirements. Therefore we took our case to the legislature and they reassigned to the Board of Healing Arts, the TCD for ED Physicians education requirements.
Seems like we were not the only group to experience problems with DHSS rules related to TCD. Our education requirement change was amended onto a bill, which also allowed hospitals to use an alternate certification process for TCD designation, AND rescinded the requirement that a barrier be placed around a medical helipad.
The House version of the Helmet repeal legislation was passed by the House and actually received debate time on the Senate floor. However in the end, Senator Doc Schaaf offered a killer amendment requiring $10M of insurance coverage for those who choose not to wear a helmet. That did the bill in for the year. MOCEP testified in opposition to the bill, as did MSMA.
Prescription Drug Monitoring Program (PDMP)
Proponents had renewed hope when the session began this year when the PDMP bill catapulted out of the House where it sat in the Senate until the final days of session. All of the coalition members looked for an avenue to pass the bill, but as the session drew to a close, the only option was to take Dr. Schaaf’s version, which was punitive to physicians. This bill and its proponents will return again in December, and one year, Senator Schaaf will not (due to term limits).
Senator Sater’s “copay for MO HealthNet ER users” bill has passed and is in the Governor’s hands. This bill requires a copayment be made by a Medicaid enrollee for use of the emergency department. Language we inserted into the bill ensures the copay does not reduce the state’s Medicaid payment to the Emergency Department.
The bill also fines Medicaid enrollees for missing appointments, with one free pass.
Several transparency bills were introduced this year, and while the legislature made it near a priority, a compromise between the physicians, hospitals and insurance companies could not be reached to clear the way for a comprehensive transparency bill. The three key pieces that did pass require requires health care providers to provide, upon a patient’s written request, including a medical treatment plan from the patient’s health care provider, an estimate of cost of a particular health care service within 3 business days. Beginning July 1, 2017, hospitals shall make available to the public the amount that would be charged without discounts for each of the 100 most prevalent diagnosis-related groups.
We exempted Emergency Departments from these requirements for obvious reasons.
The final transparency provision states that no contract between a health carrier and a health care provider shall be enforceable if such contract restricts any party to such contract from disclosing to an enrollee the contractual payment amount for a health care service.
Collateral Source, (SB847) has passed and is now on the Governor’s desk. This bill ensures medical expense awards match amounts actually paid for medical treatments, and awards do not allow the plaintiff to recover medical expenses that were neither paid nor owed. This was needed as a result of the “Deck” case which allowed full billed charges to be recovered despite those charges never being paid.
Nurses, Nurses, Nurses
The nurse bills, of which there were many, made progress until the last week, when they all fell off the cliff together. Next year I expect all of the proposals noted below to return and holding each of these short of the finish line will be difficult. We teamed up with MSMA, who did an outstanding job coordinating the opposition to these measures. One item to note, the House Professional Registration Committee, to which all of these type bills are assigned, will have a new chairperson next session, as the current Chair Eric Burlison is termed out.
The bills filed to expand the APRN scope of practice and loosening the collaborative agreement requirements included; allowing full Schedule II authority, eliminating the collaborative agreement altogether (actually making it optional – same), expanding the geographic distance, increasing the physician to collaborating APRN ratio from 3 to 5 and licensing APRN’s separately under the Board of Nursing. The two proposals that were reasonable were:
1) If an APRN changes collaborating physicians, he/she does not have to comply with 30 day on site training with the new supervising physician if the APRN does not change practice sites;
2) Expanding the 50 mile practice distance to 60 or 70 miles in rural areas. This amendment also allows review of records to be done electronically. None passed.
The HMO “copay” bill stalled after the sponsor resigned mid-session for personal reasons. This bill will sponsored by another legislator next year. I anticipate numerous conversations between providers, insurers and legislators occurring on this issue during the interim. ED physicians and pharmacists have a unique position in this issue that is slightly different than other providers since the HMO law has specific protections for those two provider groups.
This bill made significantly more progress this year, but it too hit the Senate stone wall. While it gained more traction this year, it has opposition from legislators who believe personal responsibility should outweigh banning products. The House passed the bill and even cleared the Senate Transportation committee, which allows for momentum for next session. Dr. Evan Schwarz did a great job spearheading this for MOCEP. A big thank you to him.
Finally a Step Therapy bill has passed the legislature. Everyone knew the problem but not exactly how to fix it without upending legitimate step therapy protocols. This bill was a good start. It did not go as far as many physicians and patient groups had hoped, but for the first bill to pass, it was a substantive step forward. The bill requires insurers or their agents to implement a rapid accessible appeal mechanism, and protect patients from having to repeat step therapy simply due to switching health care plans or carriers.
And finally, many of you have asked about this bill, and I won’t give you up, I promise. Medical Marijuana legislation was smoked on the House floor twice this session, despite one of the versions being scaled back to apply only to hospice patients. The proponents were token aback with it when they hit a stone wall receiving only 55 votes; 82 are needed. I am sure they will fire it (their efforts) back up next year. I fit four puns into that one issue. That is worth something!
Medicaid Managed Care
The Medicaid Statewide managed care RFP has been released and thus far the Capitol is not on fire. The responses are due back late summer, so the process remains in its infancy.