September 2016 – By Hannah L. Walsh
With passage of the 2016-2017 state budget in early July, the General Assembly recessed for the remainder of summer, not to convene again for regular business until September. When they do return, it will be for a limited number of session days before the two-year legislative session concludes at the end of November. The House of Representatives has twelve scheduled session days remaining this year; the Senate has nine.
The short schedule this fall is due to the fact that it’s an election year in Pennsylvania. When voters go to the polls to cast their vote for the next President of the United States in November, they’ll also have an opportunity to vote for their local Representative in the state House and possibly their state Senator. All 203 House seats and half of the Senate’s 50 seats are up for re-election in 2016. It’s in the weeks following the November election that legislators are considered to be least accountable to voters. Votes on legislation during this time are made by either legislators who have retired or been defeated for re-election, or who don’t have to face voters for another two to four years. Commonly referred to as a “lame-duck” session, the General Assembly stopped the practice of meeting to vote on bills after the election several years ago amidst sharp criticism and calls for reform.
While the General Assembly’s schedule this fall limits the amount of legislation action that can take place, there are a number of current issues that still have potential to move. Any bill that isn’t signed into law when the two-year legislative session concludes at the end of November will have to be reintroduced in the 2016-2017 session to begin the legislative process all over again.
The state’s opioid abuse epidemic has continued to intensify, with significantly higher rates for drug-poisoning deaths in Pennsylvania than the U.S. average. A report released in July 2016 by the DEA indicates that 3,383 Pennsylvanians died of a drug-related overdose last year – up 23.4 percent from 2014.
In an effort to stem the crisis, many states, including Pennsylvania, have enacted mandates on use of a PDMP (Prescription Drug Monitoring Program), mandates on prescriber and dispenser education, increased access for naloxone, and measures to expand treatment for substance use disorders. Some states – such as Massachusetts, Maine and New York – have taken a more radical policy approach by restricting the amount of opioids a clinician can prescribe to just a few days’ supply, with specific exceptions.
The Pennsylvania legislature is equally eager to take further action to address the proliferation of misuse and abuse of opioid prescriptions in our state. Until measurable reductions are seen in the number of opioid-related harms occurring across the Commonwealth, the number of legislative solutions proposed to this problem and the pressure to enact them will continue to grow. At the time of this writing, over fifty bills have been introduced to address what has become the leading cause of accidental death in Pennsylvania, killing more people each year than motor vehicle accidents.
On September 16, Governor Wolf called for a Joint Session of the House and Senate to focus on the opioid epidemic. The Governor also identified several policy priorities that he is encouraging legislative leaders to accomplish during the remainder of the 2015-16 session. The proposals include requiring prescribers to check the PDMP every time they prescribe; increasing education about opioid and pain management for current and future medical professionals; limiting the quantities of opioids that can be prescribed in emergency departments; requiring health insurance plans to provide coverage for abuse-deterrent opioids; adding opioid misuse to existing public school curriculum on drug and alcohol abuse; and establishing a voluntary non-opioid directive form for patients who don’t wish to receive opioids in their medical care.
At the time of this writing, PAMED is in the process of reviewing legislation introduced related to the opioid crisis, including the proposals mentioned above, and is seeking feedback from physicians so as to best represent their interests.
Prescription Drug Monitoring Program
On August 25, Pennsylvania’s new statewide prescription drug monitoring program (PDMP) went live, enabling prescribers to view the prescribing history of their patients. Prescribers are required to query the program for each patient the first time a patient is prescribed a controlled substance by the prescriber for the purposes of establishing a baseline and a thorough medical record, and if they believe or has reason to believe, using sound clinical judgement, that a patient may be abusing or diverting drugs.
In the weeks since the PDMP went live, PAMED has received numerous questions from physicians regarding various aspects of the law and what it specifically requires of them, as well as issues they have encountered with the PDMP system itself. PAMED has shared these questions and concerns with the Department of Health (DOH), charged with administering the program under the law, and has requested official clarification from the Department.
Among the questions and comments received, physicians have asked whether the administration of a controlled substance, as opposed to the prescription, necessitates a physician to query the PDMP; whether it is permissible for prescribers and dispensers to talk to each other about a patient’s prescription history if the prescriber or dispenser suspects abuse or diversion of controlled substances by the patient; if changes in dosage orders for the same controlled substance is considered a first-time prescription requiring a new query; are prescribers allowed to prescribe if the PDMP is down or undergoing maintenance and, if so, if there is anything they must do for record-keeping purposes; and more.
In addition to questions, reports of technical issues and suggestions for system improvements have also been communicated to DOH. PAMED will share with physicians any responses it receives from DOH regarding these matters and others.
Workers’ Compensation Reform
On September 13, the House Labor and Industry Committee held an informational hearing on House Bill 1141, legislation that would institute a number of important reforms to Pennsylvania’s workers’ compensation system. Representative Stan Saylor (R-York) introduced the bill this session.
HB 1141 addresses several issues with information access and reimbursement that often plague physicians who treat injured workers. For starters, the bill would ensure that providers have access to information about the injured worker’s claim, including the claim number and the description of the specific work-related injury for which the insurer has accepted liability. Workers’ compensation employers, insurers and their agents would be required to accept bills electronically, enabling reimbursements to be processed faster and with more accuracy. HB 1141 would prohibit a practice commonly referred to as “silent discounting”, where a health insurer or its “affiliates” pays providers at a discounted rate – in other words, below the mandated workers’ compensation fee schedule – without their knowledge, approval or contractual agreement. It would also prohibit insurers from using coercive tactics to compel a provider to accept discounted reimbursements. Finally, the legislation would increase penalties on payors who fail to timely implement updated fee schedules each year; define “health care provider” to clarify that the term does not include an entity that does not have a National Provider Identifier; and define “case management” according to national standards to include a variety of case management, care coordination, evaluation and management services.
During the hearing, the Labor and Industry Committee heard testimony from a panel of individuals representing organizations which strongly support HB 1141—including the Pennsylvania Medical Society (PAMED) and the Pennsylvania Orthopaedic Society (POS)—followed by individuals testifying in opposition. Members of the insurance industry and the Department of Labor and Industry opposed legislation, stating that the bill would increase costs within the workers’ compensation system without necessarily improving care.
As the meeting was informational, the Committee did not hold a vote on HB 1141.
CRNP Independent Licensure
On the evening of July 12, the Senate passed Senate Bill 717 – legislation which would allow CRNPs to practice independently and eliminate the requirement that they collaborate with physicians – by a vote of 41-9. The bill now goes to the House of Representatives for consideration, where it has been referred to the Professional Licensure Committee.
Prior to Senate passage, SB 717 was amended to require CRNPs to have a minimum of three years and 3,600 hours of experience before they can practice independently. While well-intentioned, PAMED believes the logic of this amendment was flawed. Requiring a minimum number of years or hours of work experience in an unstructured setting with highly variable experiential learning does not replace the expertise and support that comes with physician oversight, and is no match for a physician’s education and training.
PAMED has continued to express strong opposition to the legislation, which is being supported by the Pennsylvania Coalition of Nurse Practitioners (PCNP), the Hospital and Healthsystem Association of Pennsylvania (HAP), and AARP Pennsylvania, among others. On September 16, PAMED sent a “Call to Action” to all physicians, asking that they call or email their state Representative and urge his or her opposition to SB 717. If SB 717 fails to become law by the time the 2015-16 session concludes in November, the legislation will have to be reintroduced next session, which begins in January. The prime sponsor of SB 717, Senator Pat Vance (R-Cumberland), is not seeking re-election this year. A registered nurse by training, Senator Vance has for years been a strong proponent of the advancing the scope of practice and role of the nursing profession in Pennsylvania during her tenure. At this time, it is unclear who will take up the cause and reintroduce the bill next year in the Senate. Similar legislation was also introduced this session in the House of Representatives by Rep. Jesse Topper (R-Bedford) as House Bill 765.
HB 59, which was signed into law on July 20, 2016, requires all individuals born between 1945 and 1965 to be offered a Hepatitis-C screening test when receiving health services as an inpatient in a hospital or when receiving primary care services in an outpatient department of a hospital, health care facility or physician’s office. The bill provides for some exceptions to this requirement, such as if an individual is being treated for an emergency, has previously been offered or been the subject of a screening test, or lacks capacity to consent to a screening test. If an individual accepts the offer of a Hepatitis-C screening test and the result is reactive, the law ensures that a health care provider offer or refer the individual for follow-up health care, which must include a Hepatitis-C diagnostic test.
There’s no doubt that HB 59—now Act 87 of 2016—is well-intentioned and that increased Hepatitis-C testing of this at-risk population would be beneficial. However, PAMED has consistently opposed legislation that mandates aspects of the physician-patient relationship. PAMED was successful in advocating that the final version of the HB 59 contained no penalties on health care providers.
Since the law’s passage, PAMED has received a number of questions from physicians regarding its implementation. PAMED sent a letter to DOH on August 31 requesting clarification on the requirements of the Act, which is set to take effect September 18, 2016, but at the time of this writing has not yet received a response. A Quick Consult has also been made available to PAMED members to provide guidance on some of the most frequently asked questions.
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