April 20, 2007

The General Assembly had a very contentious week.

The Senate debated the Governor's proposal for the sale of MOHELA. MO Health Education Loan Authority funds for capitol improvements for state universities dominated Senate debate.

The Senate shut off debate by a parliamentary move to call the "previous question" nine times to pass the legislation.

Republicans slashed Democratic Senators projects for MU and UMKC. All this points to the Senate Democrats stalling debate and thereby killing bills for the rest of the session.

There will be a truce until the budget is passed in the Senate next week.

News of interest includes:

CAFO Senate

Senator Dan Clemens version of the CAFO legislation, SB 570, was heard on the Senate floor on Thursday. Language was inserted at our request to protect public water supplies with a one mile buffer.

After lengthy debate the Senate passed an amendment that "gutted" the entire bill and established an interim committee to study the CAFO issue.

Needless to say the Farm Bureau is upset and will continue to push the legislation.

CAFO House

Representative Munzlinger's CAFO bill, House Bill 1192, was heard in the House Local Government Committee.

Munzlinger's bill requires the Department of Natural Resources to establish rules and regulations regarding the establishment, permitting, design, construction, operation, and management of voluntarily regulated concentrated animal feeding operations (CAFOs). A voluntarily regulated facility is any CAFO with a capacity of less than 1,000 animal units that voluntarily applies to the department to be regulated and which is not otherwise required by law to have a class II permit.

Eligible voluntarily regulated facilities are not required to obtain a construction or operating permit. However, upon application to become a voluntarily regulated facility, the department has the authority to regulate the permitting, design, construction, operation, and management of the facility. Any permit issued to a class II facility prior to the effective date of the bill will remain in effect, and the facility will be considered a voluntarily regulated facility. The permit will remain in effect pending issuance of a new permit if the facility submits a timely and sufficient application and the department is unable to issue the new permit prior to the expiration date of the previous permit.

Committees Review Emergency Responder Liability Protection

A Senate committee held a hearing this week on House Bill 579. The legislation is designed to enhance the availability of health care workers to respond to major emergencies and natural disasters. It would grant immunity from medical liability to health care practitioners who volunteer to be deployed by the governor or a state agency to respond to an emergency declared by the governor. Its protections would apply to practitioners from Missouri and other states but would not extend to damages caused by willful or wanton acts or omissions.

A related bill, Senate Bill 705, was approved by another Senate committee this week. In developing the Senate Committee Substitute for Senate Bill 705, the committee scaled back the expansive liability protections of the original bill to mirror those of House Bill 579. However, it kept language allowing the governor to waive statutory or regulatory requirements that would hinder disaster response. Also, the new bill would authorize alternative standards for dispensing medications under the auspices of the Department of Health and Senior Services.

Adverse Events

Both Senate and House committees today heard identical bills that hospitals, the St. Louis Area Business Health Coalition and the Missouri Center for Patient Safety have developed regarding the governing of hospitals' response to the occurrence of a "serious adverse event in health care". The purpose of the legislation is to create an environment in which hospitals are encouraged to self-report these rare but serious incidents and work with regulators to develop plans to prevent future occurrences. More importantly, perhaps, is that patient safety organizations would be empowered to investigate these and other patient safety incidents and tell other hospitals what lessons can be learned from them. This will encourage the spread of best practices to prevent medical mistakes. The bills are House Bill 1061, sponsored by Representative Wayne Cooper, R-Camdenton, and Senate Bill 578, sponsored by Senator Bill Stouffer, R-Napton.

Physician Assistants

Yesterday afternoon, a Senate Committee approved legislation that sets new standards for the supervision of physician assistants. The House Committee Substitute for House Bill 497 now moves to the full Senate for debate.

The legislation represents a negotiated accord between several physician organizations, the Missouri Academy of Physician Assistants and hopitals. The compromise was forged in response to actions taken late last year by the State Board of Registration for the Healing Arts, which licenses both physicians and physician assistants. Facing questions regarding its legal authority, the board decided that as of August 28, 2007, it would require that physician assistants be supervised at all times by a physician practicing in the same office facility, with exceptions only as specifically authorized by law for a physician assistant's follow-up visits in hospitals, nursing homes and jails.

The House Committee Substitute for House Bill 497 would set a default standard that a physician assistant must be supervised by a physician working in the same facility 66 percent of the time the physician assistant is providing patient care, with exemptions for follow-up visits in hospitals, nursing homes, jails and patient homes. The bill also creates a process for waiving the 66 percent standard that involves review and recommendation by the state Advisory Committee on Physician Assistants and a final decision on the waiver application by the State Board of Registration for the Healing Arts. The board’s waiver decisions are to be based on uniformly applied criteria regarding the adequacy of supervision, distance between the physician and physician assistant, and the potential for reduced access to services without a waiver. Waivers would be limited to practice settings that at the time of application were included in a designated health professional shortage area. The bill also sets various standards for physician assistant training and contracts and agreements for physician assistant supervision.

Midwives

Yesterday, the Senate gave first-round approval to legislation that would create a system of occupational licensure for direct-entry midwives. Noting that Senators who previously had been involved in a filibuster on the bill were absent from the chamber, the bill's supporters brought the bill up for debate and approved it immediately before opponents could block the move. The bill now needs a final vote by the Senate before it advances to the House. Opponents will need to be vigilant to block that final Senate vote. If the bill passes the Senate, it is virtually assured of becoming law.

Senate Substitute for Senate Bill 303, sponsored by Senator John Loudon, R-Ballwin, would require that these licensed midwives be recognized as certified professional midwives by the North American Registry of Midwives. The bill requires licensees to provide patients with written disclosure statements describing their experience, training, liability insurance coverage, risks and benefits of home births and a client-specific plan for transfer to medical care. The disclosure would not be required for those who have passed a skills assessment test of the North American Registry of Midwives and practiced midwifery for at least 20 of the 30 years before August 28, 2007.

A licensure board for direct-entry midwives would be created. Various limitations also are placed on the practice of a direct-entry midwife, who may not prescribe drugs, use forceps during deliveries, or perform cesarean sections, medical inductions or vacuum deliveries.

The bill limits who may be held liable for a direct-entry midwife's negligent acts or omissions. However, it does not preclude other providers from being liable for their own negligence in providing follow-up treatment. The liability language reiterates current legal standards.

Universal Health Care

Yesterday, a Senate Committee approved Senate Committee Substitute for Senate Bill 122, sponsored by Senator Joan Bray, D-St. Louis. The original bill established a universal health care system based on the Canadian model. However, the committee substituted the bill with language which simply establishes a commission to study the issue. The Missouri Universal Health Assurance Commission would study the possible implementation of a universal health assurance program for Missouri to provide a publicly financed, statewide program that will provide comprehensive health care services for Missouri residents. The commission would be composed of 25 members, of whom 16 members are appointed by the governor.

This bill will not pass.

Planned Parenthood Out of Classroom if Bill Passes Planned Parenthood would be kicked out of the classroom under a bill moving forward in the House.

Rep. Therese Sander's (R-Moberly) bill places new regulations on abortion clinics, making them comply with the same regulations that ambulatory surgery centers do. It creates the "Missouri Alternatives to Abortion Services Program". The program will counsel pregnant women, continuing for a year after birth, assisting them to carry their fetus to term instead of having an abortion. It also will assist women in caring for their children or in putting their children up for adoption.

But the portion of HCS HB 1055 that created the most heated exchanges during House floor debate centered on who should teach sex education in the classroom and how it should be taught.

The bill prohibits any abortion provider from teaching sex education. Sander makes no bones about what she is targeting, stating, "We don't have to rely on Planned Parenthood which is in the business of killing our children."

HCS HB 1055 also allows school districts to offer sex education consistent with the federal abstinence program. Rep. Beth Low (D-Kansas City) says teaching abstinence−only fails to take into account the real world of teen-agers, "Ignorance is not a form of birth control."

Low says some parents don't do a good job of talking to their children about sex and it falls to the schools to provide comprehensive sex education. The bill needs another positive vote to move to the Senate.

Missouri Senate Approves MOHELA Plan

The Missouri Senate endorsed a plan early today to turn $350 million of student loan assets into college construction projects, but only after Republican leaders abruptly terminated debate and punished two Democratic opponents. The dramatic steps were taken as Senate leaders hope to revive Gov. Matt Blunt's stalled college spending plan, funded with assets from the Missouri Higher Education Loan Authority, or MOHELA.

The plan has faced repeated setbacks since it was announced 15 months ago. Most recently, Democrats who oppose the plan have relied on the time-honored Senate filibuster, debating the bill for hours to prevent a vote.

Just after 12:25 a.m. today, the Senate forced a vote by approving a motion to "move the previous question," a rare maneuver that has been used to end debate on only seven bills since 1970.

And in a step that further angered Democrats, Republican leaders then voted to strip $46 million of construction projects from campuses in two Democratic districts. On the chopping block is a cancer research center at the University of Missouri − Columbia, and a nursing and pharmacy education building at UM−Kansas City.

The cuts are in retaliation to Sens. Chuck Graham, D-Columbia, and Jolie Justus, D-Kansas City, who had threatened to prolong debate on the bill indefinitely.

An enraged Senate Minority Leader Maida Coleman, D-St. Louis, accused Republicans of trampling Senate tradition in a purely partisan effort.

"This is about forcing a bad public policy down our throats simply because the governor had a bad idea," she said.

Coleman told Republican leaders that their votes had destroyed the spirit of cooperation that she said should prevail in the Senate.

"The Senate is now dead and the blood is on your hands," she said.

But Senate President Pro Tem Mike Gibbons, R-Kirkwood, said the Senate followed its own rules in cutting off debate.

He said leaders in the Republican majority did all they could to negotiate with Democrats, allowing more than 30 hours of debate on the MOHELA plan this session. In the end, he said, obstructionism by Democrats threatened a vital bill, he said.

"You can have a tyranny of the majority and you can have a tyranny of the minority," he said in an interview.

Gibbons also stood by the decision to strip the spending plan of projects in districts represented by Graham and Justus. Gibbons said the two senators chose not the support the projects when they threatened to defeat the entire bill.

But Graham said Senate leaders are responsible for letting politics stand in the way of a $31 million cancer research center at UM−Columbia.

"What they are trying to do is shift the blame," he said in an interview. "What they need to do is make decisions in the best interest of the state."

The college-spending plan has been Blunt's highest priority since last year. The legislation would expand the mission of MOHELA to allow it to spend $335 million on campus projects and $15 million to market and encourage biotechnology research. Critics say the plan could imperil the loan authority, which secures access to low-cost student loans.

"I suggest we forget about this bill and focus on truly giving our students the ability to attend college for years to come," said Sen. Joan Bray, D-University City. For most of the day Wednesday, Bray and other Democrats prolonged the debate on the plan by offering more than a dozen amendments, some only loosely tied to MOHELA. The Senate defeated one such amendment by Sen. Tim Green, D-Spanish Lake, that would have given tax breaks to cover tuition costs for households earning less than $150,000 a year.

Another amendment would deny MOHELA funding to any campus that knowingly hires a convicted sex offender. The measure is in response to revelations that a professor from Missouri State University is on the state's sex offender registry.

The amendment passed. But one senator warned that Republican leaders were growing weary of the extended debate. "The clock is ticking and the time is coming," said Sen. Jason Crowell, R-Cape Girardeau.

Ultimately, Senate leaders allowed more than nine hours of debate before forcing the vote. The plan was approved by a vote of 21−12. It must now receive a second vote before moving to the House.

Supporters of the plan say MOHELA has already been able to raise $211 million for the plan by selling student loan assets. Under the latest version of the bill, MOHELA could sell additional loans or have the option of issuing bonds to continue funding the campus projects.

But most of the political heat around the plan has centered not on finances, but on fears by anti-abortion groups that the funds could support embryonic stem cell research. In response, Blunt has stripped the plan of projects related to human life science research. Doing so won the support of many anti−abortion lawmakers. But the changes have failed to satisfy the state's anti−abortion organizations, while angering supporters of life science research.

Often lost amid the MOHELA debate is the fact that the higher education bill also includes a litany of new proposals for the state's public colleges and universities. Among those measures is a plan to merge the state's two largest needs-based scholarships. The new scholarship would give eligible students up to $1,000 a year to attend community college, $2,150 to attend a public university and up to $4,600 to attend a private university.

The bill would also penalize schools that raise tuition at a rate that exceeds inflation, as measured by the consumer price increase.

Prior to Thursday, the last time the Senate voted to move the previous question was last year, to approve a bill requiring voters to show photo identification.

The bills are SB389 and HB16.

Bill Limits Legal Settlements by Governmental Agencies

Senate Bill 491 was approved by a Senate committee this week. The bill concerns the ability of a state or local government entity — which would include a public hospital — to settle a lawsuit involving allegations that a person's civil or constitutional rights have been violated if the proposed settlement would affect the future conduct of the governmental entity's employees. Unless the governmental entity's attorney attests in writing that the settlement would not infringe on the employees' civil or constitutional rights, the employees must be notified of the proposed settlement. Also, the governmental entity must provide an attorney to represent the interests of employees who object to the settlement. If the objecting employees cannot negotiate a resolution regarding the settlement agreement, they will be permitted to intervene in the court proceeding.

Committee Advances HPV Proposal

The Senate Seniors, Families and Public Health Committee reviewed several proposals to change the laws on immunizations required for school attendance. The original version of Senate Committee Substitute for Senate Bill 514 added inoculation for the human papilloma virus to the list of required immunizations for school attendance. However, the Senate Committee Substitute removes the mandate and instead allows parents to "opt-in" their children. The bill would apply to female students entering grade six. The Department of Health and Senior Services is required in the bill to provide information to parents or guardians of female students regarding the connection between human papilloma virus and cervical cancer.

Committees Review Bills on Patient Safety and Adverse Events

This week, Senate and House committees reviewed identical bills relating to patient safety. One component of Senate Bill 578 and House Bill 1061 would provide state statutory recognition for patient safety organizations. These organizations would be authorized to analyze information disclosed to them by health care providers and develop recommended best practices for preventing medical errors and promoting patient safety. The organization's patient safety work product and discussions or findings in reviewing patient safety data would be protected from disclosure and not admissible in lawsuits.

A 2005 federal law created standards and legal protections for patient safety organizations, but implementing regulations have not been issued yet. The Missouri Center for Patient Safety, the Missouri State Medical Association and Primaris, would be designated under both the federal and proposed state laws.

Senate Bill 578 and House Bill 1061 also address how hospitals, regulators and patient safety organizations will respond to the occurrence of a "serious adverse event in health care." These are 28 incidents defined by the National Quality Forum. If the hospital reports the incident to the Department of Health and Senior Services, performs a root cause analysis, and supplies a corrective plan of action to prevent future occurrences, the incident will not be regarded as a licensure deficiency. As such, it would not be publicly disclosed.

In conjunction with hospitals and a patient safety organization, the department would develop criteria for defining cases in which reportable incidents have occurred with a frequency or pattern to necessitate licensure sanctions to protect the public.

The incident also would be reported to a patient safety organization, which would analyze reported data and develop and share recommendations with all hospitals regarding incident prevention and best practices. The patient safety organization would issue an annual report on reportable incidents, which would show the number and rate per patient encounter by geographic region and category of adverse event.

House Advances Bill Changing Laws on Newborn Genetic Testing

The Missouri House of Representatives initially approved House Committee Substitute for House Bill 948 this week. The bill must still receive final approval in the House before moving on to the Senate for debate. If passed, the bill would revise standards governing the Department of Health and Senior Services' retention of laboratory specimens and their use in public health research. Also, the results of genetic screening tests on newborns could be released by the department to the child's health care provider. The bill also specifies how appropriated funds may be used by the state to subsidize the purchase of costly dietary formula needed to treat those with various metabolic disorders, such as PKU.

House Advances Bill Regulating Abortion and Sexual Education

House Committee Substitute for House Bill 1055 was given initial approval by the Missouri House of Representatives this week. If passed, the bill would establish the Missouri Alternatives to Abortion Services Program, revise current law on sexual education, adds "medical emergency" defense language for those who violate Missouri's abortion law, and adds abortion providers to the "ambulatory surgical center" definition. The new Alternatives to Abortion Program would provide services or counseling to pregnant women and assistance to women in caring for their children or placing them up for adoption. Counseling and services are available to a woman during her pregnancy and for one year after the birth of her child. The department or departments administering the programs may contract with public or private agencies to provide services or counseling. This bill is a companion bill to Senate Committee Substitute for Senate Bills 370, 345 and 432.

Legislature Approves Children’s Vision Bill

Senate Committee Substitute for Senate Bill 16, sponsored by Sen. Delbert Scott, R-Lowry City, received final approval by the Missouri House of Representatives this week. This bill had already received final approval by the Missouri Senate. If signed by the governor, this bill would require that each child enrolled in kindergarten or first grade receive a comprehensive vision examination.

House and Senate Committees Review Bills

Several bills affecting health care delivery were given their initial committee hearings this week. They include the following:

• House Bill 690 would create a system of occupational licensure for naturopathic physicians.
• House Bill 643 would prohibit state government from purchasing or paying for a vaccine unless it is an "ethical vaccine", defined as one produced from a cell culture not derived from an aborted fetus. The requirement would take full effect in 2010.
• House Bill 682 would require physical fitness facilities to have at least one automatic external defibrillator and a staff member trained in its use. The requirement would not apply in certain settings, including fitness facilities located in a hospital.
• House Bill 1067 would expand liability protections applicable to the use of an automatic external defibrillator. The protections would apply to the owner of the equipment and the entity or person providing medical management of its use.
• House Bill 1135 would authorize the State Legal Expense Fund to provide liability insurance coverage for specialist physicians when they provide free care to patients referred to them by certain clinics. The specialist could provide the care in his or her office rather than in the clinic. The legislation is designed to improve access to specialty care for low-income uninsured patients.
• Senate Bill 269 moves the State Emergency Management Agency from the Office of the Adjutant General to the Department of Public Safety.

Next Week

The Senate will address their version of the Budget and House and Senate conferees will hammer out the differences.

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