2018 OCACS Annual Meeting
- The 2018 OCACS Annual Chapter Meeting will be held April 6-7, 2018 at the Westin Cincinnati. We look forward to seeing you there!
2018 OCACS Annual Meeting
CRNA Scope of Practice, Anti-MOC Bills Could See Movement
The 132nd General Assembly returns to action this month for a busy spring work period. The legislature is expected to tackle a handful of contentious issues before departing at the end of May. Lawmakers will consider a state capital budget, Congressional redistricting reform, legislation to shore up Ohio’s unemployment compensation program, and a broad education reform bill. Ohio’s Medicaid budget seems stable for now, though Congressional inaction on CHIP and potential changes to the Affordable Care Act by the Trump Administration could complicate matters. On the healthcare front, the General Assembly has a number of bills pending in each chamber. As previously reported, the Ohio House Insurance Committee plans to hold hearings on House Bill 416, which seeks to modify Ohio’s health price transparency law.
There are two other pieces of legislation that the Ohio Chapter is monitoring closely. House Bill 191, sponsored by State Rep. Anne Gonzales (R-Westerville), would grant independent practice authority to nurse anesthetists by removing the current physician supervision requirement. The bill comes on the heels of enactment of HB 216 in the 131st General Assembly, which made several changes to the scope of practice for other nurse practitioners. The Ohio Chapter along with the Ohio State Medical Association and the Ohio Society of Anesthesiologists have expressed concerns with the measure. House Bill 273, sponsored by State Rep. Theresa Gavarone (R-Bowling Green), would prohibit hospitals and insurance plans from requiring maintenance of certification (MOC) as a condition of employment or reimbursement. Anti-MOC bills have been introduced in a number of states as frustration has grown between physicians and credentialing bodies. HB 273 appears on hold following a meeting held last month between several national physician organizations and the American Board of Medical Specialties.
Ohio Governor’s Race Narrows as Filing Deadline Approaches
At one point, the race to succeed Ohio Governor John Kasich (R) featured four Republican candidates and six democratic candidates. Thankfully, the last couple of weeks have seen a number of candidates drop out. Candidates for the Office of Governor must file their petitions by February 6th in order to be on the May Primary Ballot. The most significant campaign shake-up came on the Republican side, where Ohio Secretary of State Jon Husted opted to end his candidacy and become Ohio Attorney General Mike DeWine’s running mate. DeWine and Husted were considered to be the top two candidates on the Republican side. Further, following State Treasurer Josh Mandel’s termination of his candidacy for United States Senate, Ohio Congressman Jim Renacci announced he would end his campaign for Governor and instead run for Senate. With Husted on DeWine’s ticket and Renacci seeking a US Senate seat, the only other Republican candidate for Governor is current Ohio Lieutenant Governor Mary Taylor; most pundits and experts believe DeWine will easily win his party’s nomination for Governor.
The Democratic side of the Governor’s race remains more fractured, despite the departure of a handful of candidates. As we entered 2018, State Senator Joe Schiavoni, former Congresswoman Betty Sutton, former State Representative Connie Pillich, Dayton Mayor Nan Whaley, former Ohio Attorney General Richard Cordray, and Ohio Supreme Court Justice Bill O’Neill were all seeking the Democratic nomination for Governor. Congresswoman Sutton ended her campaign and joined Cordray’s ticket as a candidate for Lt. Governor. Further, Mayor Whaley ended her campaign and endorsed Cordray. Unfortunately for the Democratic Party, former Congressman and Fox News Contributor Dennis Kucinich stunned many political insiders by announcing his candidacy for Governor earlier this month. Kucinich had not previously indicated an interest in running for Governor, but enjoys strong name ID across Ohio. The Democrats now have five candidates (Cordray, Schiavoni, Kucinich, Pillich, O’Neill) seeking the party’s nomination for Governor. This presents several challenges for the Democratic Party considering the opposition seems to be coalescing around the DeWine/Husted ticket. Expect more surprises over the next few weeks as February 6th approaches.
State Controlling Board Votes to Sustain Medicaid Expansion
Earlier this week, the State Controlling Board approved the release of $264 million in state funding for the Ohio Department of Medicaid (ODM). These funds represent the state share of funding for coverage of the Expansion population for State Fiscal Years 2018 and 2019. Monday’s unanimous vote by Controlling Board will allow ODM to draw down an additional $638 million in federal matching funds. The requirement that ODM seek Controlling Board approval for Medicaid Expansion funding was included in House Bill 49, the State Operating Budget for FY18/19; HB 49 was signed by Governor Kasich on June 30th.
The State Controlling Board is a spending oversight panel comprised of legislators and chaired by an appointee of the Governor. The board approves contracts, authorizes appropriation increases, and in limited cases approves the release of funds for certain purposes. Controlling Board was the same entity that Kasich used to expand Medicaid coverage in 2014. The Board approved a major appropriation increase for ODM following expansion of the Medicaid program through authority granted to the Ohio Medicaid Director. In addition to requiring Controlling Board approval for Expansion, HB 49 also included language prohibiting ODM from expanding coverage in the future without legislative approval.
This vote does not mean Medicaid Expansion is safe in Ohio. The Ohio House of Representatives could still vote to override Governor Kasich’s veto of language in HB 49 freezing Expansion enrollment in FY19; the Ohio Senate would have to follow suit. Additionally, any changes to Medicaid at the federal level, including a repeal of the Affordable Care Act, would put Expansion at risk. Finally, Medicaid Expansion has become a target for at least two Republican candidates for Governor, meaning it could be put on the chopping block in 2019 after Kasich’s successor takes office.
Voters to Decide Fate of Issue 2 (Drug Price Relief Act)
On Tuesday, voters will be asked to wade into the debate of drug prices through Issue 2, a proposed statute that would tie drug prices paid by state and local entities to the price paid by the U.S. Department of Veterans Affairs. The proposal is backed by the AIDS Healthcare Foundation, who unsuccessfully pursued a similar measure in California last year. While proponents claim Issue 2 would save taxpayers $400 million, the State Office of Budget and Management as well as other independent studies have argued those savings are hard to predict and unlikely to materialize. Issue 2 is opposed by a large coalition of business and healthcare provider organizations, hospitals, and charities. Most of the funding to defeat Issue 2 has come from PhRMA.
Ohio Senate Follows Through on Veto Overrides; More Votes Looming
As previously reported, the Ohio House of Representatives met in July and voted to override 11 of Governor Kasich’s 47 line item vetoes in House Bill 49, the State Operating Budget for Fiscal Years 2018 and 2019. The Ohio Senate did not immediately convene to follow suit, however Senate President Larry Obhof (R-Medina) indicated that votes were likely in August and September. The Ohio Senate met last week and took 6 of the 11 House veto overrides; this now marks the first time in four decades that the General Assembly has voted to override a Gubernatorial line item veto. President Obhof has scheduled session on September 6th to consider the remaining veto overrides and the House can still call up any other veto to override when legislators return next month. Among Governor Kasich’s vetoes is language that would have frozen Medicaid Expansion enrollment beginning in July 2018; the House could take this up next month.
The Senate action preserves language requiring the Ohio Controlling board, a spending oversight panel, to approve the release of funds for Medicaid Expansion in the future; another veto override will place limits on funding increases that the Board can act on without legislative approval. Two veto overrides will result in increased Medicaid reimbursement for nursing homes and neonatal service provides, respectively. Governor Kasich’s Office of Health Transformation has been pushing to redesign behavioral health service reimbursement within Medicaid, however that effort will not be delayed until July 2018 under another veto override. Finally, the last veto override will retain language requiring future expansions of Medicaid eligibility to be approved by the legislature. These veto override votes come as Governor Kasich travels across the nation promoting a bipartisan healthcare reform plan with Governor John Hickenlooper (D-Colorado).
Governor Kasich Announces New Opiate Prescribing Rules
Following months of action by the State Medical Board of Ohio, the State of Ohio Pharmacy Board, and other regulatory bodies, Governor Kasich announced the adoption of rules limiting the amounts of opiates that can be prescribed for acute pain. The Ohio Chapter of the American College of Surgeons provided comments throughout the development of these rules and was able to achieve a number of positive changes. These rules are the latest effort by Governor Kasich and legislative leaders to stem the diversion and abuse of prescription opiates. Thankfully, the number of opiate prescriptions and resulting overdose deaths are on the decline. Under the new rules, opiate prescriptions for acute pain are generally limited to five days for children and seven days for adults. Further, the rule caps the total Morphine Equivalent Dose of an opioid analgesic prescription at 30 MED.
If a physician believes that a longer prescription or higher MED is appropriate, then he or she may prescribe above these limits so long as the rationale is noted in the patient’s medical record. These rules become effective on August 31st. These rules only apply to acute pain; chronic pain and prescriptions related to treatment for cancer, palliative or hospice care, or drug addiction are exempt. Another rule, developed by the Pharmacy Board and effective on December 29th, would require the first four alphanumeric characters of a CPT code to be included on any schedule II opiate prescription. This requirement expands to all controlled substances beginning July 1st, 2018. The Ohio Chapter of the American College of Surgeons expressed opposition to the Pharmacy Board CPT Rule and we continue to work with other physician organizations that have similar concerns over the cost and necessity of this mandate.
General Assembly Considers Line Item Veto Overrides
We previously reported that the Ohio General Assembly was considering override votes on several of Governor Kasich’s line-item vetoes in HB 49, the State Operating Budget for FY 18/19. Kasich vetoed 47 provisions prior to signing the budget late last month. Many of these vetoes struck down provisions related to Medicaid coverage in Ohio. The Ohio House of Representatives convened on July 6th and voted to override 11 of Governor Kasich’s vetoes. This is the first time that either chamber of the General Assembly has voted to override a line-item veto in more than three decades. The Ohio Senate is expected to return next month to consider the House veto overrides.
Of the 11 veto overrides considered by the Ohio House, ten dealt with Medicaid. Most notably, Kasich’s veto of language freezing Medicaid Expansion enrollment was not part of the vote. The General Assembly could still take up that override later in the year; however for now Medicaid Expansion in Ohio appears safe. Generally, the House veto overrides had the effect of asserting greater legislative control over the Medicaid program, delaying key Kasich Administration priorities, and selectively increasing Medicaid rates to certain providers. It is unclear if the Senate will take up all 11 veto overrides; the Senate cannot bring up other vetoes not previously voted on by the House.
Medicaid Rate Cuts Looming Following Passage of Budget
While many voters and healthcare advocates are focused on Washington, DC and potential Medicaid cuts in the Congressional Republican plan, the Ohio Department of Medicaid might be forced to reduce provider rates in the current fiscal year to address a projected funding shortfall. Recently, Governor Kasich’s Budget Director, Tim Keen, told reporters that the state operating budget approved last month (HB 49) did not fully fund Ohio’s Medicaid program. Based on the Kasich Administration’s projections, there is a $1.4 billion gap in Medicaid funding over the fiscal biennium.
The Ohio Hospital Association and other healthcare organizations, along with some members of the General Assembly, feel that this figure is high and that the Ohio Department of Medicaid is assuming a higher growth rate than is necessary. The state just finished FY 17 with Medicaid underspending of more than $1.1 billion; there has definitely been a trend in the past few state fiscal years of Medicaid expenditures coming in below estimate. Despite pushback from legislators, hospitals, and providers, the Ohio Department of Medicaid is considering provider reimbursement reductions of 5%-11%. . Further cuts might be needed should the Ohio Senate vote to override some of the Governor’s line-item vetoes in HB 49 (see above).
Ohio Prepares to Seek ACA State Innovation Waiver
The Section 1332 Waiver, also known as the State Innovation Waiver, is one of the lesser known provisions in the Affordable Care Act (ACA). The waiver, which only became effective on January 1st, would grant states an exemption from many of the ACA’s insurance mandates (essential health benefits, individual coverage, employer coverage, etc.) for five years if a number of conditions are met. To qualify for a 1332 waiver, a state would have to demonstrate through regulations, subsidies, and programming that it could offer insurance coverage at least as adequate as ACA-mandated coverage in that state. So far, only one state (Alaska) has had an innovation waiver approved.
While Governor Kasich has been a critic of recent Congressional attempts to repeal and replace ACA, he has historically been an ACA critic and seems open to pursuing a 1332 waiver. Further, the Ohio Department of Insurance recently launched a website to gather feedback on a potential state innovation waiver. And language was included in HB 49, the State Operating Budget for FY18/19, requiring the Ohio Department of Insurance to apply for a 1332 waiver by January 31st, 2018. Given the continued roadblocks that Congressional Republicans are facing with healthcare reform, the state innovation waiver might become a popular tool for GOP Governors and Republican-controlled State Legislatures to craft an ACA-alternative.
General Assembly Wraps Up State Budget
Earlier this week, the Ohio General Assembly passed House Bill 49, the state operating budget for FY18 and FY19. The republican-led state legislature approved HB 49 largely along party lines, wrapping up nearly six months of committee hearings, debates, and amendments. Governor Kasich must sign the budget by June 30th and is expected to line-item veto a number of provisions, including some Medicaid-related measures (see below).
The General Assembly rejected Governor Kasich’s entire tax reform package, which included an income tax cut paid for through increases in the state sales tax, tobacco tax, and severance tax on oil and gas drilling. Governor Kasich’s sales tax expansion would have impacted elective cosmetic surgery—the Ohio Chapter, along with other allies, worked to remove this provision. During Ohio House consideration of HB 49, lawmakers added a provision requiring health plans to cover telemedicine services. The Ohio Senate removed this measure and it was not reinserted during Conference Committee.
Governor Kasich included language in his budget proposal that would have repealed Ohio’s controversial health price disclosure law. Two years ago, lawmakers added this language to the previous operating budget (HB 64). It required healthcare providers to provide patients with a good faith estimate of total charges, insurance reimbursement, and projected out-of-pocket costs for any non-emergency service. After several unsuccessful attempts to modify this unworkable law, the Ohio Hospital Association and other healthcare groups including the Ohio Chapter filed a lawsuit to overturn the law. The General Assembly removed language in HB 49 repealing the health price disclosure law, effectively restoring the current law that is the subject of the OHA lawsuit.
Finally, lawmakers included a provision that would have freeze hospital reimbursement for Medicaid at FY17 levels. This was in response to a Kasich Administration proposal to reduce hospital reimbursement following enactment of HB 49. Governor Kasich is expected to veto this provision and due to declining state revenues, the Ohio Department of Medicaid is projecting a shortfall in funding for the fiscal biennium. To close this gap, the Department might propose a 5% across the board rate cut for all Medicaid providers.
Future of Medicaid Expansion in Ohio
Citing unsustainable growth in Medicaid spending, Republican Lawmakers took aim at Medicaid Expansion in HB 49, adding a number of provisions to curb and limit the program. The debate over Medicaid Expansion in Ohio paralleled Congressional action on Healthcare Reform and any future changes to Medicaid funding at the federal level will force tough decisions for every state.
Most notably, the Ohio Senate adopted a freeze in new enrollment for the Expansion population (Group 8) beginning in FY 19, or July 1st, 2018. This freeze is estimated to reduce Medicaid enrollment by 500,000; adults struggling with mental health issues or drug addiction would still be allowed to enroll. Governor Kasich is expected to veto the Medicaid Expansion freeze provision, though Republican legislative leaders have indicated the General Assembly could return next week to override the veto.
In addition to freezing Medicaid Expansion, lawmakers also adopted other provisions aimed at increasing requirements for adults enrolled in Medicaid. Under language approved by both the Ohio House and Ohio Senate, adults enrolled in Medicaid must either be over 55, employed or in school, struggling with drug addiction, or have a serious mental or physical health issue to be eligible for coverage. Additionally, legislators added a provision requiring the Ohio Department of Medicaid to establish the HealthyOhio program; this program would establish HSA’s for adults enrolled in Medicaid and require monthly contributions. Both of these provisions require approval by the Centers for Medicare and Medicaid Services.
Finally, lawmakers placed new restrictions on Medicaid funding and reimbursement. Language in HB 49 would require any rate increases to be approved by the Joint Medicaid Oversight Committee and state funding for Medicaid Expansion must be authorized by the Ohio Controlling Board. Should Congress enact legislation that reduces the enhanced reimbursement rate for Medicaid Expansion, Ohio’s program would be abolished.
Medical marijuana will be legal in Ohio on Sept. 8, 2016. But it may still be another two years before patients will gain access to the drug for medicinal purposes. In the meantime, authorities from several different state agencies have the task of drafting and establishing specific rules, regulations and guidelines for how the drug will be cultivated, processed, tested, and eventually dispensed to Ohio patients.
In June, Ohio became the 25th state to pass legislation to make medical marijuana when Ohio Gov. John Kasich signed House Bill 523. The state has since established an official website, the Ohio Medical Marijuana Control Program, that will provide news, information and other resources about the state law as developments occur. State agencies involved include the State of Ohio Board of Pharmacy, State Medical Board of Ohio, and the Ohio Department of Commerce.
The Ohio State Medical Association (OSMA) supports the use of those drugs prescribed for medicinal purposes that have previously been clinically researched and approved by the Food and Drug Administration (FDA). Because Ohio’s law allows for medical use of marijuana without conclusive clinical research as to the drug’s benefit the OSMA did not support HB 523. The OSMA, however, commended the Ohio legislature for establishing a responsible regulatory process that allowed for debate and the sharing of ideas for how Ohio would best implement a medical marijuana law.
The 2016 OHACS Annual Meeting was held May 6 – 7 at the Embassy Suites Columbus Airport hotel in Columbus, OH. Initial feedback leads to the meeting being successful in that presentations were timely and pertinent as well as adequate networking time was afforded for attendees. Thank you to all that attended. Continue reading
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SECOND PLACE Continue reading