POLITICAL PULSE: Legislative Highlights of the Week, Including MaineCare Limits on Prescribing for Pain
In another Saturday session (February 4th), the Joint Standing Committee on Appropriations and Financial Affairs met to further discuss the Governor's Supplemental Budget and voted unanimously to limit MainceCare coverage of opioid medication in order to generate savings in the MaineCare drug budget and to address the issue of prescription drug abuse, diversion and addiction in the State. Once these recommendations are included in the Supplemental Budget, which is now a virtual certainly, there will be an immediate impact on many physicians and patients. Please read this entire article to understand the full implications of these proposals. MMA is particularly concerned that the proposals now impact prescriptions for both acute pain and chronic pain, with exceptions for cancer pain, aids patients, hospice patients and inpatients of a hospital.
SUPPLEMENTAL BUDGET DELIBERATIONS
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 led 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 both acute pain and chronic 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 and to limit the refills to another 15 days with an absolute cap at 45 days. 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 he or she chose to do so. The major change from last week's report is that the proposal is now likely to expand beyond new prescriptions to even patients who have been on opioid medication for years. The proposed effective date for this provision is April 1, 2012. For a MaineCare member who, on April 1, 2012, was receiving opioids for the treatment of chronic pain for one year or longer continuously the application of the provision begins on September 1, 2012.
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 budget language on all of these proposals will be posted on the MMA web site, www.mainemed.com.
The above provisions have the unanimous support of the Committee members, it appears. This coming week, the Committee is expected to present its proposals to the full legislature, but limited to those changes that will impact between now and July 1, 2012, the end of the exiisting state fiscal year.
INSURANCE COMMITTEE REJECTS BILL PROVIDING INSURANCE COVERAGE FOR TOPICAL FLUORIDE TREATMENT FOR KIDS, CONTINUES WORK ON "SPECIALTY TIERS" IN PRESCRIPTION DRUG COVERAGE
Last Monday, the Insurance & Financial Services Committee voted that L.D. 1666, An Act to Guarantee Basic Preventive Dental Health for Children in Maine, ought not to pass. The bill would have required insurance companies to cover fluoride treatments at least twice annually and was championed by Augusta pediatric dentist and past President of the Maine Dental Association, Jonathan Shenkin. The MMA spoke in favor of its passage.
The Committee requested that a group of stakeholders meet to discuss 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. The MMA participated in the meeting, however it appears that there is little consensus between patient advocates and insurance carriers. The Committee takes up the bill again tomorrow. The MMA encourages you to contact Committee members to urge their support for this bill. Committee members can be found here and you can look up your legislators here.
MMA TESTIFIES BEFORE THE HHS COMMITTEE ON MAINECARE AUDITS, PRESCRIPTION DRUG DATA DISCLOSURE, INVOLUNTARY COMMITMENT
The Health and Human Services Committee has been busy finalizing work on carry over bills and new legislative proposals. The MMA has been closely following their efforts and testified on several bills last week. On Tuesday, the Committee heard public comments on LD 1629, which would allow the state to enter contingent fee agreements with MaineCare Recovery Audit Contractors. In testimony in opposition to the bill, Gordon Smith, MMA EVP, reminded the Committee that the state had previously allowed contingent fee agreements with auditors but barred them in statute after very bad experiences. While the federal government does allow for contingent fee agreements in both the MaineCare and Medicare RAC programs, the MMA believes the state is not obligated to implement this fee structure. The Maine Osteopathic Association and Maine Hospital Association also testified in opposition. The Committee work session on the bill is tomorrow.
The MMA also testified on LD 1679, which repeals the statue that created Maine's prescription drug privacy laws and allowed physicians to opt-out of having their prescribing information shared with drug manufacturers. Maine's law was found unconstitutional In light of a US Supreme Court's decision this summer on Vermont's similar law. While the MMA does not oppose the repealing of the statute in light of the court decision, the MMA believes that there is still more the state can do to protect the privacy of prescribers' and patient's data and is proposing several options to the Committee. The Committee will have a work session on the bill this Wednesday.
Finally, Mr. Smith testified on behalf of the MMA and Maine Association of Psychiatric Physicians in favor of LD 1688. This bill would clarify that getting "blue papered" or transferred to a psychiatric facility does not constitute being "committed" for purposes of reporting to employers, licensing boards or other entities.
The Committee also held work sessions on several other bills, including:
- The Committee voted to pass an amended version of LD 1624, which removes the requirement that an application for a medical laboratory license be notarized, clarifies that specimens may be collected or processed by licensed health care professionals as well as their designees, and removes the requirement that a licensed medical laboratory send a copy of an itemized statement of laboratory services to the patient. The amendments addressed some of the MMA concerns with the bill, though the MMA still believes that patients should be provided a copy of their bill.
- The Committee tabled LD 1628, An Act to Limit Payment for Care and Treatment of Residents in State Institutions. The bill
proposes to limit reimbursement for any medical services by community providers to the Medicaid rate for medical services provided in the community to residents of the Riverview Psychiatric Center and the Dorothea Dix Center. Currently community providers receive charges. The Committee appears to have been swayed by the Maine Hospital Association and agrees the State should reimburse more than MaineCare rates but wants to see something less than charges.
- The Committee voted to pass LD 1627, which expedites electronic filing of vital records.
CRIMINAL JUSTICE COMMITTEE HEARS GUN POSSESSION BILLS, DISCUSSES CARBON MONOXIDE DETECTORS
Last week, the Criminal Justice and Public Safety Committee took up several bills of interest to the MMA. On Monday the Committee heard public testimony regarding LD 1603, which would allow state employees to keep a firearm in their vehicle on state property as long as the vehicle was locked and the firearm was not visible. This bill expands on a bill passed last session that allowed private-sector employees to bring guns onto employer property. The Maine Chamber of Commerce, Maine Citizens Against Handgun Violence, and private business owners testified in opposition to the bill, stating that it prevented employers from being able to create their own gun policies and reduced workplace safety. The Committee also heard testimony regarding LD 1728, which would prevent an out of state resident from getting a concealed handgun permit in Maine if they had applied for and been denied a concealed handgun permit by their state of residence. The Department of Public Safety proposed this bill. MMA is monitoring both pieces of legislation.
The Committee is also considering LD 1744, which would expand the existing laws regarding carbon monoxide detectors to require that newly constructed inns, hotels, motels, dormitories, fraternities and sororities install carbon monoxide detectors. On Friday, the Committee voted to table the bill to give them time to gather more information from colleges about their abilities to install the detectors.