Legislative Update for August 31, 2017

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).

Read More: Cleveland Plain Dealer: Ohio Senate Overrides six of Gov. John Kasich’s budget vetoes

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.

Read More: Columbus Dispatch:Kasich hopes pain-pill limits will reduce opioid addiction

Fact Sheet: State Medical Board of Ohio:New Limits on Prescription Opioids for Acute Pain

Legislative Update for July 27, 2017

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.

Read More: Toledo Blade: Ohio House Votes to Override Kasich

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).

Read More: Columbus Dispatch: Kasich Says Legislature Has Left Medicaid $1.4 Billion Short

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.

Read More: Cleveland Plain Dealer: Ohio is Trying to Get Out of Obamacare Requirements

Legislative Update for June 29, 2017

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.

Read More: Columbus Dispatch: $65.5 billion state budget passes; veto battle with Kasich looms

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.

Read More: Columbus Dispatch: Lawmakers’ Medicaid freeze sets up Ohio budget showdown with Kasich

Ohio Medical Marijuana Officially Becomes Law in September

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.

2016 Ohio Chapter, ACS Annual Meeting

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

Congratulations to the OCOT Paper Competition Winners

First Place

Multiple Methods to Increase Sphingosine Rescue Burn Mice from Lung Pseudomonas Aeruginosa Infection
Presented by Dr. Teresa C. Rice, University of Cincinnati Medical Center

Second Place

Endothelial Cells Endocytose Microparticles from Aged Red Blood Cells
Presented by Dr. Young Kim, Department of Surgery, University of Cincinnati

OCOT Trauma Paper Competition

Submission Deadline Extended!
Deadline to submit abstracts extended to Wednesday, April 27 at 5:00 pm.

The competition is open to all general surgery residents, surgical specialty residents and trauma fellows.  Medical students are not eligible.

Continue reading

Provisions in the 2016 Medicare Physician Fee Schedule that will affect surgical practice: An overview

New payment policy and coding and reimbursement changes set forth in the 2016 Medicare Physician Fee Schedule (MPFS) final rule took effect January 1, 2016. The MPFS, which the Centers for Medicare & Medicaid Services (CMS) updates annually, lists payment rates for Medicare Part B services and introduces and updates a number of other policies affecting physician reimbursement and quality measurement. On September 8, 2015, the American College of Surgeons (ACS) submitted comments related to the MPFS proposed rule. These comments provided feedback to CMS on a number of policies outlined in the final rule released October 30, 2015. Although the MPFS final rule introduces important payment and policy changes that affect all physicians, this article focuses on updates that are particularly relevant to general surgery and its related specialties.

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