POLITICAL PULSE: Legislative Highlights of the Week, Including Limits on Prescribing for Pain
In an unusual Saturday session (1/28), the Joint Standing Committee on Appropriations and Financial Affairs met to further discuss the Governor's Supplemental Budget and made some preliminary decisions on prescribing of opioid medication that are aimed at generating savings in the MaineCare drug budget and at addressing the issue of prescription drug abuse, diversion and addiction in the State. If these recommendations are indeed included in the Supplemental Budget, which is likely, there will be an immediate impact on many physicians and patients. Please read this entire article to understand the full implications of these proposals.
SUPPLEMENTAL BUDGET DELIBERATIONS
Nearly all of Saturday's deliberations and negotiations involved the general subject of prescription drug abuse, diversion and addiction. The proposed two year limit on Suboxone, noted in last week's Update, has been vigorously resisted by MMA, the Northern New England Society for Addiction Medicine, the Maine Association of Psychiatric Physicians, the Maine Association of Substance Abuse Programs and others. By the end of the day Saturday, these efforts were partially rewarded when the Committee agree to delay any prior authorization for patients on Suboxone until January 1, 2013. This extension was granted for the purpose of allowing MaineCare officials to work with members of the addiction treatment community in determining reasonable criteria for the review at the two-year point. MaineCare officials are to report back to the Committee in September 2012, regarding the results of these efforts. This work would be lead by the MaineCare DUR Committee with consultation from the MaineCare Physician Advisory Committee and the Substance Abuse Services Commission.
Partially to find funds to offset the change in the Suboxone proposal, Committee members looked to limits on the prescribing of opioid medication for acute pain. Currently, MaineCare allows an initial script for 15 days but has no limits on renewal, resulting in patients receiving such medications for an average of seventy (70) days. The Committee has proposed continuing the 15 day limit on the original script, but requiring any refill to be subject to a prior authorization process. In addition, no renewals could exceed another 30 days or 45 days total. Certain illnesses and conditions would be exempt including cancer and AIDS. If a patient received a renewal beyond the 45 days, he or she could pay for the medication themselves if they chose to do so.
The Committee also made two further recommendations that do not generate any savings in the budget but are seen as important in the renewed effort to prevent diversion and addiction. Recognizing that the state's Prescription Monitoring Program (PMP) is now six years old but that many prescribers of pain medication are not registered to access the information, the Committee voted to mandate registration in the PMP in 2014 among any class of prescribers which has not achieved ninety (90) percent participation by January 1st of that year. The individual classes would be medical doctors, doctors of osteopathy, dentists, nurse practitioners, physician assistants and podiatrists. At this point, the proposal addresses only registration for the PMP, not actual usage.
Finally, a handful of legislators wanted to address the issues related to physician assistant and nurse practitioner prescribing of pain medications. The only recommendation at this point involves PA's and provides that the supervising physician would have to review the PA's prescribing practices on a yearly basis as part of the written plan of supervision currently required by the Board of Licensure in Medicine. Proposals impacting on APRN's have not yet been circulated.
The Committee is struggling with many other elements of the Governor's proposal. While February 1st was a deadline for agreement imposed by the Governor, the Committee today is not much closer to agreement on the other major issues than they were a month ago. So it is unclear what other items might be in or out of the Supplemental Budget. And while there is still time to make changes in the proposals described above, most Committee members believe that their work is done in that area.
INSURANCE COMMITTEE HOLDS HEARINGS ON BILLS REQUIRING INSURANCE COVERAGE FOR TOPICAL FLUORIDE TREATMENT FOR KIDS, PROHIBITING "SPECIALTY TIERS" IN PRESCRIPTION DRUG COVERAGE
Last Wednesday, the Insurance & Financial Services Committee held a public hearing on L.D. 1666, An Act to Guarantee Basic Preventive Dental Health for Children in Maine, a bill championed by Augusta pediatric dentist and past President of the Maine Dental Association, Jonathan Shenkin. As a compromise with Northeast Delta Dental, Dr. Shenkin proposed an amendment to require coverage for two, rather than four, topical fluoride treatments per year in any dental insurance plan or any health insurance plan that provides dental benefits. In addition to Dr. Shenkin, other proponents included the Maine Dental Association, MMA, and the Maine Chapter of the American Academy of Pediatrics. The state's health insurers opposed the bill while Northeast Delta Dental spoke "neither for nor against" it.
On Wednesday afternoon, the Committee held a public hearing on L.D. 1691, An Act Related to Specialty Tiers in Prescription Drug Pricing. The bill would prohibit health insurers from including in plan designs so-called "specialty tiers" whereby the insurance carrier includes a fourth or even a fifth tier of drug coverage beyond the typical three tiers. These specialty tiers have a co-insurance rather than a co-payment obligation by the patient and pose a significant cost barrier to patients with chronic conditions needing expensive drugs. Based upon feedback from the oncology and rheumatology communities, the MMA spoke in favor of the bill. Patient advocacy groups in hemophilia, MS, and cancer also expressed concern about these specialty tiers. Again, the insurance carriers opposed the bill.
The Committee has scheduled a work session both bills for this Wednesday, February 1st. The MMA encourages you to contact Committee members to urge their support for these bills. Committee members can be found here and you can look up your legislators here.
MMA OBJECTS TO TWO DHHS BILLS BEFORE THE HHS COMMITTEE
Last Thursday, the Health and Human Services Committee held public hearings on a series of bills submitted by the Department of Health and Human Services (DHHS). Two of them were troublesome to MMA. The MMA expressed concern about two aspects of L.D. 1624, An Act to Lessen the Regulatory Burden on Medical Laboratories by Removing Outdated Requirements for the Maine Medical Laboratory Act. The DHHS representative who spoke at the hearing offered an amendment to address one of MMA's concerns. The amendment would permit qualified lab personnel, other than a physician, to assist in obtaining specimens whereas the original bill required a physician only to obtain a specimen. The bill also eliminated a sentence in current law that would require the patient to be provided with a copy of the bill for laboratory fees. The MMA pointed out a physician's ethical obligation to provide a copy of the laboratory bill and it appeared that the Committee was interested in retaining this provision. Spectrum Medical Group also expressed concern about these provisions.
The MMA also objected to L.D. 1628, An Act to Limit Payment for Care and Treatment of Residents of State Institutions. DHHS submitted this bill specifically to address medical services provided in the community to residents of the Riverview Psychiatric Center and the Dorothea Dix Center, and proposes to limit reimbursement for any medical services by community providers to the Medicaid rate. The Maine Hospital Association also objected to this proposal.
The Committee will hold a work session on both bills this Thursday afternoon.
HHS COMMITTEE TAKES FINAL ACTION ON CARRYOVER LEGISLATION
In addition to the new bills taken up, described above, the Health and Human Services Committee also held work sessions and took final votes on a number of
bills carried over from last year of interest to the MMA.
Committee voted unanimously that LD 612, requiring insurance and
MaineCare reimbursement for Medication Management Therapy by
pharmacists, ought not to pass. The MMA opposed the bill and the
payors expressed concern about the cost.
- The Committee also voted unanimously that LD 646 ought not to pass. The original bill would have put into law a number of specific
requirements that prescribers must follow when prescribing antipsychotic medications to children
in the MaineCare program. Last session, the Committee
instead agreed to direct the Department
of Health and Human Services (DHHS) to convene a committee to study the
use of antipsychotic medications in children. The group met a number
of times this fall and presented the Committee with a report and the
commitment by DHHS to work with all DHHS agencies and clinics to
implement a Continuous Quality Improvement process and prescribing
guidelines for the use of antipsychotic medications in children. In
place of the bill, the Committee is instead sending the Commissioner of
DHHS a letter asking for a report back on progress by December 2012 and
to work with the MMA and other provider organizations to share the
prescribing recommendations. MMA opposed the
original bill but participated in the study and supports the next steps
of the group.
Committee did pass an amended version of LD 806, An Act to Provide
Public Access to Price Lists of Hospitals and Ambulatory Surgical
Facilities. The original text of the bill would have required hospitals and ACSs to post publicly and on their websites prices
charged by the facilities for the 100 most commonly performed
procedures in the facility. While Committee members shared that costs transparency is
very important for patients and reducing health care costs, they
acknowledged that the Maine Health Data Organization is already required
to gather and report cost data. In place of the original bill, the amended legislation would require that MHDO provide more up-to-date data to the
public on their website.
Committee voted unanimously that LD 1354, An Act to Improve the Quality
and Reduce the Cost of Health Care, ought not to pass. The
bill directed the Department of Health and Human Services to coordinate
the purchase of prescription drugs for MaineCare members through 340B
covered entities in order to reduce costs. MMA monitored this bill.
Committee also voted that LD 936 ought not to pass. This bill, An Act
to Conform Maine Menu Labeling Laws to Federal Standards, would have
repealed provisions of state law regarding
nutrition labeling for restaurant menus that
overlap with new requirements under the federal Patient Protection and
Affordable Care Act. The Committee agreed to wait to take any action
that would repeal the state law until they can see the federal
regulations spelling out what the federal requirements will be.
Committee tabled action on LD 1114, To Improve Preventive Dental Health
Care and Reduce Future Avoidable Costs, pending a final outcome on the
DHHS budget. The bill would allow MaineCare to provide
and restorative dental services and partial or full dentures, when DHHS
determines that the dental services are medically necessary to and
will be cost-effective in comparison to the provision of other covered
medical services for the treatment of that condition. The Committee determined that this bill may become moot if budget negotiations end all MaineCare dental coverage for adults.
ED COMMITTEE TAKES STEPS TO PROTECT KIDS FROM BULLYING, HEAD INJURIES
Education Committee last week passed LD 98, a bill that will require
the Commissioner of Education to propose and distribute a policy on the
management of head injuries in school activities and athletics and to
convene a working group to advise the Commissioner on the prevention,
diagnosis and treatment of concussive and other head injuries. By July
1, 2012 all public schools will have to adopt a policy in line with that
proposed by the Commissioner. Former New England Patriots linebacker Andre Tippett and a spokesperson for the NFL both testified in favor of the measure before the final vote. The Committee also took final action on L.D. 1237, An Act to Prohibit Bullying in Schools,
voting unanimously that the bill ought to pass. Representatives of the
Maine Civil Liberties Union, Maine School Management Association
(representing school boards and superintendents) and the Maine
Principals' Association presented the Committee came to agreement and
presented the committee with amended language that will require schools
adopt anti-bullying policies and procedures. Both bills now proceed to a floor vote.