The Governor has until today to sign or veto legislation passed during the 2017 State Legislative session. On the last day of the 2017 fiscal year, June 30, Governor Greitens signed the budget to begin the Fiscal Year 2018, July 1.

BUDGET:

Due to lower than expected tax receipts from 2016 and rising healthcare costs, the Governor is restricting more than $250 million to keep a balanced budget. Here are the details of the  restrictions.

For the first time in over a decade, the Foundation Formula will be fully funded, adding $133 million to the public school system.  Many of the new cuts to the budget are in the health care provider reimbursements (1.5% less). 

HEALTH CARE LEGISLATION:  Greitens signed Senate Bill 50, relating to health care issues.  A summary of the issues included in the bill is at the end of this report. 

Governor Greitens also signed Senate Bill 139, which is also relating to health care issues and had more prescription drug issues.  MONA supported the bill to protect the MO Rx program. The program helps low-income Missourians pay for their prescription drugs. The entire MO Rx program was scheduled to expire in August 2017. Governor Greitens and the legislature extended the MO Rx program until at least 2022 for more than 182,000 Missourians.  A full summary of the legislation is below.

Governor Greitens signed Senate Bill 503 into law, which is relating to emergency services.  Although the 911 legislation for the entire state did not pass, this legislation will designate a statewide coordinator for 911 services across the state and requires that the Department of Public Safety shall conduct a study by December 31, 2017, relating to 911 answering points and issue a state public safety answering point consolidation plan based upon the study.  A full summary of the bill is below.

SPECIAL SESSIONS:  There was rumor of the Governor calling a Special Session to address the Prescription Drug Monitoring Program; however, since the second Special Session for abortion issues is still going on, it is less likely there will be a Special Session on other issues.  The Senate is supposed to reconvene in late July to finish the Special Session on abortion.

BOARDS & COMMISSIONS:  The Boards and Commissions Task Force (chaired by Lieutenant Governor Mike Parsons) met on Tuesday, at the Capitol, to discuss various boards and commissions and their activity.  The committee met all day; however, they did not discuss Professional Registration boards or Insurance.  Those will be discussed at the next Task Force meeting on Thursday, August 3, at 11:00 a.m., at the Capitol.

The committees goal is to look at what boards are inactive, have not met, do not have enough appointed to constitute a quorum, etc.  Then they will make recommendations to the Governor and state legislature.  Legislation will be needed in most all cases to eliminate or merge any boards.

That is a quick run-down on what’s happening in politics throughout the state.  Please let me know if you have any questions at kynaiman@earthlink.net

BILL SUMMARIES:

SB 50 – This act modifies several provisions relating to health care, including: (1) STEMI and trauma center designations; (2) newborn screening; (3) neonatal and maternal levels of care; (4) x-ray inspections; (5) a health care directives registry; (6) hospital licensure; (7) hospital employment of dentists; (8) assistant physicians; and (9) speech-language pathologists and audiologists.

STEMI AND TRAUMA CENTER DESIGNATIONS (Sections 190.241 and 190.242)

Under this act, the Department shall promulgate rules for the designation of a trauma center and a STEMI center without site review if such hospital is certified by a national body.

Additionally, a hospital may apply for STEMI center designation as follows: (1) a Level I STEMI center if such hospital has been certified as a Joint Commissions Comprehensive Cardiac Center or another approved nationally-recognized organization or (2) a Level II STEMI center if such hospital has been accredited as a Mission: Lifeline STEMI Receiving Center by the American Heart Association or another approved nationally-recognized organization.

No rule or regulation promulgated by the Department of Health and Senior Services shall require hospitals, as a condition of trauma, STEMI, or stroke center designation, to obtain emergency medical services data, unless such data may be obtained from the state database for emergency medical services. Additionally, a hospital shall not be required to comply with an interpretation of a specific provision in a regulation concerning trauma, STEMI, or stroke centers if the hospital can demonstrate that the interpretation of such provision was different for a similarly-situated hospital, unless the Department has subsequently and consistently interpreted such provision for similarly-situated hospitals. The Department shall attend meetings with trauma, STEMI, and stroke centers for the benefit of improved communications, best-practice identification, and facilitation of improvements to the designation process.

Finally, this act removes the requirement that the Department generate quarterly regional and state outcome data reports for trauma, stroke, and STEMI centers, the State Advisory Council on EMS, and regional EMS committees.

NEWBORN SCREENING (Section 191.332)

This act requires the Department of Health and Senior Services, beginning January 1, 2019, and subject to appropriations, to expand current newborn screening requirements to include spinal muscular atrophy and Hunter syndrome.

NEONATAL AND MATERNAL LEVELS OF CARE (Section 192.380)

Under this act, the Department of Health and Senior Services shall hold public hearings and establish criteria for levels of maternal care designations and neonatal care designations for birthing facilities. Beginning January 1, 2019, any hospital with a birthing facility and any such hospital operated by a state university shall report to the Department its appropriate level of maternal care and neonatal care designations. The Department may partner with nationally-recognized nonprofit organizations with relevant expertise to administer the provisions of this act.

X-RAY INSPECTIONS (Section 192.500)

This act provides that inspections of cone beam computed tomography systems and panoramic x-ray systems that cannot produce radiation intensity greater than thirty milligrays shall not be required to be inspected more frequently than every 3 years. Cone beam computed tomography systems that can produce radiation intensity greater than thirty milligrays shall be inspected annually. Additionally, all cone beam computed tomography systems and panoramic x-ray systems shall be inspected within thirty days of installation and whenever moved within an office.

A cone beam computed tomography system is a medical imaging device which uses x-ray computed tomography to capture data using a cone-shaped x-ray beam. A panoramic x-ray system is an imaging device that captures the entire mouth in a single, 2-dimensional image that includes the teeth, upper and lower jaws, and surrounding structures and tissues.

This act also provides that inspections of conventional x-ray equipment used exclusively on animals by a licensed veterinarian or veterinary facility shall not be required to be inspected more frequently than every 4 years.

HEALTH CARE DIRECTIVES REGISTRY (Section 194.600)

This provision requires the Department of Health and Senior Services to contract with a third party for the establishment of a health care directives registry for the purpose of providing a place to securely store an advance health care directive online and to give authorized health care providers immediate access to the directive. The third party contractor shall be solely responsible for the administration and maintenance of the registry. All data and information contained in the registry shall remain confidential and shall be exempt from the Sunshine law. An “advance health care directive” is defined as either a power of attorney for health care or a declaration signed by an adult declarant containing the person’s direction concerning a health care decision.

All documents shall be submitted electronically to the registry at intake points, such as licensed health care providers and licensed attorneys, and signed electronically with a unique identifier, such as a Social Security number, a driver’s license number, or another unique government-issued identifier. The electronic submission will be accompanied by a fee not to exceed ten dollars.

The Department may promulgate rules to carry out theses provisions, which may include, but not be limited to, a determination of who may access the registry, including physicians, other licensed health care providers, the declarant, and his or her legal representative or designee.

HOSPITAL LICENSURE (Sections 197.005, 197.040, 197.050, 197.070, 197.071, 197.080, and 197.100)

Under this act and beginning July 1, 2018, compliance with Medicare conditions of participation shall be deemed to constitute compliance with the standards for hospital licensure in this state. Nothing in this act shall preclude the Department of Health and Senior Services from promulgating regulations, with specific statutory authorization, to define separate regulatory standards that do not duplicate the Medicare conditions of participation. Regulations promulgated by the Department that duplicate or conflict with Medicare conditions of participation shall lapse and expire on and after July 1, 2018.

This provision contains a delayed effective date of July 1, 2018.

HOSPITAL EMPLOYMENT OF DENTISTS (Section 332.081)

Under this act, licensed hospitals shall be permitted to employ any of the following providers to treat certain conditions for hospital patients: (1) licensed dentists, (2) licensed oral and maxillofacial surgeons, and (3) licensed maxillofacial prosthodontists.

ASSISTANT PHYSICIANS (Section 334.036)

This act modifies the definition of “assistant physician” to allow any medical school graduate who has met the requirements to be an assistant physician between August 28, 2014, and August 28, 2017, to be deemed to be in compliance with the requirements of becoming an assistant physician.

SPEECH-LANGUAGE PATHOLOGISTS AND AUDIOLOGISTS (Section 345.051)

This act provides that license renewal for speech-language pathologists and audiologists shall occur no less frequently than every three years. Additionally, the continued competence requirements for licensed speech-language pathologists and audiologists may include up to 30 hours triennially of continuing education, examination, self-evaluation, peer review, performance appraisal, or practical simulation.

SB 139 – This act modifies provisions relating to health care.

EMERGENCY ADMINISTRATION EPINEPHRINE (Section 196.990): This act allows a physician to prescribe epinephrine (EPI) auto-injectors in the name of an authorized entity for use in certain emergency situations. Pharmacists, physicians, and other persons authorized to dispense prescription medications may dispense EPI auto-injectors under a prescription issued in the name of an authorized entity. An “authorized entity” is defined as any entity or organization at or in connection with locations where allergens capable of causing anaphylaxis may be present, including but not limited to restaurants, recreation camps, youth sports leagues, amusement parks, and sports arenas.

This act also allows such authorized entities to acquire and stock a supply of EPI auto-injectors under a prescription issued in accordance with the provisions of the act. An employee or agent of an authorized entity or any other person who has completed the required training shall be allowed to use the EPI auto-injector on the premises of or in connection with the authorized entity to provide it to any individual who the employee, agent or other person believes in good faith is experiencing anaphylaxis, regardless of whether the individual has a prescription for the EPI auto-injector or has been previously diagnosed with an allergy. The employee or agent shall not administer or provide the auto-injector to a person who is eighteen years of age or younger without the verbal consent of a parent or guardian who is present at the time, unless the child will be in imminent danger without the use of the auto-injector.

The act specifies the required training and the procedures for making the EPI auto-injectors available to individuals other than trained persons, as long as the auto-injectors are secured and properly stored. The act also requires all basic life support ambulances and stretcher vans to be equipped with EPI auto-injectors and staffed by at least one person trained in the use of the auto-injectors.

This act exempts certain persons and entities from liability for any injuries or related damages that result from the administration or self-administration of an EPI auto-injector in accordance with the provisions of the act that may constitute ordinary negligence. The immunity shall not apply to acts or omissions constituting reckless disregard for the safety of others, or willful or wanton conduct, and shall be in addition to and not in lieu of the protections provided under the Good Samaritan emergency law. No trained person who is in compliance with this law and who in good faith and with reasonable care fails to administer the EPI auto-injector shall be liable for that failure.

POLYPHARMACY & ANTIPSYCHOTIC MEDICATIONS (Section 208.227): This act repeals existing language relating to psychotrophic medications and adds new language relating to the establishment of a polypharmacy program and the prescribing of antipsychotic medications. The MO HealthNet Division shall establish a polypharmacy program for high-risk MO HealthNet participants with numerous or multiple prescribed drugs. The Division shall also establish a behavioral health pharmacy and opioid surveillance program to encourage the use of best medical evidence-supported prescription practices. The Division shall issue provider updates to enumerate specified treatment and utilization principles for MO HealthNet providers, including treatment principles relating to antipsychotic drugs.

If the Division implements any new policy or clinical edit for an antipsychotic drug, the Division shall continue to allow MO HealthNet participants access to any antipsychotic drug that they use and on which they are stable or that they have successfully used in the past. Additionally, the following shall apply to the prescribing of antipsychotics:

(1) If an antipsychotic drug is listed as “non-preferred” by the Division and is considered clinically appropriate for an individual patient, prior authorization shall be simple and flexible;

(2) If an antipsychotic drug is listed as “non-preferred” and is known or found to be safe and effective for a patient, the Division shall not restrict the patient’s access to the drug and such drug shall be considered “preferred” for that patient;

(3) A patient shall not be required to change antipsychotic drugs due to changes in medication management policy, prior authorization, or a change in the payor responsible for the benefit; and

(4) Patients transferring from state psychiatric hospitals to community-based settings shall be permitted to continue their medication regimens.

The Division’s medication policy and clinical edits shall provide MO HealthNet participants initial access to multiple FDA-approved antipsychotic drugs that have substantially the same clinical differences and adverse effects that are predictable across patients and whose manufacturers have entered into rebate agreements with the federal Department of Health and Human Services. The act specifies the categories of available drugs that shall be made available to participants.

PRESCRIPTION DRUG REBATES (Section 208.229): Under this act, pharmaceutical manufacturers shall pay to the state of Missouri, in accordance with federal law, rebates on eligible utilization of covered outpatient drugs dispensed to MO HealthNet participants as follows: (1) for single source drugs and innovator multiple source drugs, rebates shall reflect the manufacturer’s best price; and (2) for single source drugs and innovator and noninnovator multiple source drugs, any additional rebates as necessary to account for certain price increases in excess of inflation.

MISSOURI RX PROGRAM (Sections 208.790 & 208.798): The act modifies provisions relating to the Missouri Rx Prescription Drug Program by requiring applicants’ household income limits for eligibility to only apply to Medicaid dual eligible individuals.

The provisions of the Missouri Rx Program are extended and shall sunset on August 28, 2022.

DELEGATION OF PHYSICAL THERAPY TREATMENT (Section 334.506): Currently, a physical therapist may delegate physical therapy treatment to a person in an entry level of a professional education program approved by the Commission for Accreditation of Physical Therapists and Physical Therapist Assistant Education. This act modifies the name of the relevant commission to the Commission on Accreditation in Physical Therapy Education (CAPTE).

RX CARES FOR MISSOURI PROGRAM (Sections 338.700 & 338.710): This act also creates the Rx Cares for Missouri Program to be administered by the Board of Pharmacy in consultation with the Department of Health and Senior Services. The goals of the program are to promote medication safety and prevent prescription drug abuse. The Board may expend funds appropriated to the Board to private and public entities for the development of programs and education in order to meet these goals. Funds shall not be used for any state prescription drug monitoring program.

The Board of Pharmacy may enter into interagency agreements with the Department of Health and Senior Services so that the Department may assist in the operation of the program. The program shall expire on August 28, 2019.

SB 503 – This act modifies provisions relating to emergency services.

EMS MEDICAL DIRECTORS – 190.103

The act modifies the designations and duties of state and regional EMS medical directors, including that regional EMS directors shall be considered public officials for certain purposes, the state EMS medical director’s advisory committee shall be considered a peer review committee and eligible to participate in certain programs, allowing regional medical directors to provide medical direction by telecommunication, and provisions allowing regional medical directors to promulgate treatment protocols for patients with special needs and requiring EMS agencies to follow those protocols.

EMT LIABILITY – 190.144

The act provides that no emergency medical technician shall be liable, if acting in good faith and without gross negligence, for the administration of a patient’s personal medication when deemed necessary.

ANSWERING POINTS STUDY – 190.450

The act requires that the Department of Public Safety shall conduct a study by December 31, 2017, relating to 911 answering points and issue a state public safety answering point consolidation plan based upon the study.

MISSOURI 911 SERVICE BOARD – Sec. 650.320, 650.325, & 630.330

The act changes the name of the Advisory Committee for 911 Service Oversight to the Missouri 911 Service Board.

The number of Board members is reduced from 16 to 15, and the composition of the Board is changed. The Board shall have no authority over certain emergency communications services providers. No corporation or its affiliate shall have more than one member on the Board, subject to the exception that all members appointed as of August 28, 2017, shall continue to serve the remainder of their terms. Additional new powers and responsibilities of the Board are specified including compliance with federal standards, coordinating services, planning and implementing improvements to technological systems, and collaborating with other bodies of state government.

The Board is required to designate a coordinator who shall be responsible for overseeing state 911 operations.

A deadline relating to rulemaking authority is modified and extended to August 28, 2017.

The section modifying the Missouri 911 Service Board contains an emergency clause.

STATE AUDITOR’S AUTHORITY TO CONDUCT PERFORMANCE AND FISCAL AUDITS (Section 1)

The act authorizes the State Auditor to conduct performance and fiscal audits of any board, dispatch center, joint emergency communications entity, or trust fund involving emergency 911 service.