May 2, 2008

Only two weeks remain in the 2008 legislative session. The House and Senate Conference Committee members met throughout the week to negotiate the difference between their versions of the budget.

The Senate Appropriations Chair Nodler has “slashed” literally all the new spending items. Nodler’s rationale for the cuts is basically that he does not want to fund increases this year due to the anticipated budget downturn next year. He commented he would then have to cut core funding if the funding had any increases.

On Tuesday, Nodler commented that sales tax revenues are now coming in at 2.2% as opposed to the projected 5% rate.

In a huge move Tuesday evening, Nodler made a motion that was passed to cut the entire $40 million the Governor wanted for Insure Missouri that would have placed 200,000 additional Missourians classified as working poor to those covered by insurance.

This reflects the seriousness of the legislators view on the state of the budget.

News this week includes:

Immunization

The House Health Care Policy Committee met and heard Senate Bill 778, Senator Justus.

The bill provides that female students enrolling in sixth grade may receive, at the option of a parent or guardian, an immunization for the human papillomavirus (HPV). The Department of Health and Senior Services shall directly mail age appropriate information to parents or guardians of female students entering grade 6 regarding the connection between HPV and cervical cancer and the availability of the HPV immunization. Such information shall include the risk factors for developing cervical cancer, the connection between HPV and cervical cancer, how it is transmitted and how transmission can be prevented, the latest scientific information about the immunization's effectiveness, information about the importance of pap smears, and a statement explaining that questions from parents or guardians may be answered by a health care provider.

Subject to appropriations, if a parent or guardian chooses to have the female student immunized for the HPV infection but is unable to pay, the student shall be immunized at public expense at or from the county, district, city public health center or a school nurse or with the costs of immunization paid through the Mo HealthNet program, private insurance or in a manner to be determined by the department of health and senior services subject to state and federal appropriations.

Beginning July 1, 2009, the department shall submit to the general assembly a report detailing the number of sixth grade female students who have and have not been immunized against the HPV infection and the number of non-responses to the request for the written statement. The information derived from the written statement shall be used for statistical purposes only and shall not be used to personally identify any parent or guardian, or any student.

This act is substantially similar to SCS/SB 514(2007).

Pharmacy

Senate Substitute #2 for Senate Committee Substitute for House Committee Substitute for House Bill 1619 received final approval from the Missouri Senate late yesterday. The bill already has been approved by the Missouri House. Changes made in the Senate now must be accepted or rejected by the House before moving to the governor for his signature.

The bill creates a database for monitoring drug prescriptions in the state and requires that prescription information — including a patient's name, address and date of birth — be recorded in a central database that could be accessed by law enforcement agencies and several state regulatory boards. Prescriptions that have some potential for abuse, Schedule II, III, IV or V controlled substances, would be stored in the database. The purpose of the bill is to combat doctor shopping — the practice of collecting multiple prescriptions for illicit uses. The bill contains an exemption for prescriptions for controlled substances: (1) prescribed for in-patient hospital care or (2) prescribed at the time of discharge from the hospital. The bill also includes more strict requirements for purchasing over–the–counter drugs containing pseudoephedrine, a methamphetamine precursor.

An amendment added to the bill would allow advanced practice registered nurses who meet certain requirements to prescribe Schedule III, IV and V controlled substances.

Legislators Advance Insure Missouri but Delete Funding

Earlier this week, the Missouri Senate voted 30–4 to advance Senate Substitute for Senate Committee Substitute for Senate Bill 1283. The bill has moved to the Missouri House and now awaits a hearing there. The bill contains several provisions including Insure Missouri, health care quality data transparency and adverse events reporting. Analysis of the bill was provided in last week's update.

Within two hours of the Senate's passage of Senate Bill 1283, a committee of senators and representatives convened to continue its work negotiating the differences between the House and Senate versions of the appropriations bills for the Department of Health and Senior Services and the Department of Mental Health (House Bill 2010) and the Department of Social Services (House Bill 2011).

Funding of the Insure Missouri program was among the topics of discussion. In an unexpected move that ran counter to earlier conversations with committee leaders, the committee approved a motion by its chairmen to remove funding for the Insure Missouri program from the budget. The rationale offered was that since separate legislation to authorize Insure Missouri did not appear likely to pass this session, the money could be used elsewhere in the budget.

The chair of the Senate Appropriations Committee said he was acting on comments made by Speaker of the House Rod Jetton, R–Marble Hill, during a press conference last week. Jetton had suggested that the Insure Missouri authorizing legislation was "on life support." Both the Senate and House Budget Committee chairmen committed to funding the Insure Missouri program in a supplemental appropriations bill if authorizing legislation was passed this session. To be funded during this calendar year, the governor would need to call a special session, most likely concurrent with the veto session scheduled for September.

House Speaker Rod Jetton and Rep. Rob Schaaf, R–St. Joseph, continue to block passage of Insure Missouri by insisting that it be linked to certificate of need reform which will kill "Insure MO". This is their plan.

Stroke, STEMI Center Proposal Advanced by Senate Panel

Senate Committee Substitute for House Committee Substitute for House Bill 1790 was advanced by the Senate Health and Mental Health Committee this week. The legislation would authorize the creation of a “time critical diagnosis” system for the initial emergency treatment of stroke and STEMI (ST-elevation myocardial infarction, in which a cardiac artery is completely blocked. STEMIs account for about 10 percent of heart attacks).

The Senate Committee Substitute adds two other bills to the proposal: House Bill 1546 and House Bill 1805. House Bill 1546 requires hospitals to have a plan addressing control of MRSA and authorizes the use of an alternative indicator "head–of–bed elevation" to measure hospitals' efforts to prevent ventilator–associated pneumonia in ICU patients. Earlier versions would have required reporting by Public Health. We successfully worked to have that deleted. House Bill 1805 says that if the usual and customary retail price of a prescription drug is less than the normal insurance co–payment amount, the patient will pay the lesser amount.

The premise of House Bill 1790 is that clinical research shows that patient outcomes improve significantly if appropriate treatments can be administered within specified time frames. The bill would permit ambulance transport protocols to direct stroke and STEMI patients to hospitals with the capabilities to deliver the appropriate treatments within time deadlines. If distance or other factors are such that transport to a designated center could not be completed in time, the patient would go to the nearest hospital, as under current law. The transport standards would be driven by clinical research and implemented through state regulations or a community or regional stroke/STEMI plan.

House Committee Approves Bill Modifying Forensic Exams

Senate Substitute for Senate Bill 1159 was approved by the House Crime Prevention and Public Safety committee and modifies provisions on forensic examinations of sexual assault victims. The bill has already been approved by the Senate and now moves to the full House for debate.

Language in the bill codifies an executive order from Gov. Matt Blunt by moving payments to medical providers for forensic exams of sexual assault victims from the Missouri Department of Health and Senior Services to the Missouri Department of Public Safety. Medical providers are reimbursed for the exam's cost with money from the newly created Sexual Offense Forensic Examination Compensation Fund. The fund consists of money from the crime victim' compensation fund, general revenue and federal funds.

In addition, if the medical provider reasonably believes the sexual offender is the victim's parent or guardian and the victim is under 18, the medical provider only is required to provide written notice of the exam to the non–offending parent or guardian.

Bill Allowing Advanced Practice Nurses to Prescribe Controlled Substances Approved

The Missouri House voted this week 125–17 to approve House Committee Substitute for Senate Committee Substitute for Senate Bill 724. The bill would permit an advance practice nurse to prescribe certain controlled substances under the auspices of a collaborative practice arrangement with a physician.

The bill was amended during House Floor debate to include language placing stricter requirements for purchasing over–the–counter drugs containing pseudoephedrine, a methamphetamine precursor. The bill has already been approved by the Senate. However, the Senate now must accept or reject the changes to the bill made by the House before the bill is sent to the Governor for his signature.

Under current law, advanced practice nurses may prescribe drugs under a collaborative practice arrangement with a physician, but controlled substances are excluded. The proposed legislation would permit advanced practice nurses to prescribe schedule III, IV, and V controlled substances. Schedule III narcotics would be limited to a 120–hour supply without refills. An advanced practice nurse would need to complete specified coursework and training before being allowed to prescribe controlled substances.

The bill specifies that it will not affect the ability of a certified registered nurse anesthetist to administer anesthesia under the supervision of a physician who is immediately available if needed. However, CRNAs will not be authorized to prescribe controlled substances under the auspices of a collaborative practice arrangement in other settings.

The legislation also states that it will not supersede hospital licensure standards regarding standing orders or protocols for delivering medication in inpatient or emergency hospital care, if the protocols are approved by the hospital medical staff and drug therapeutics committee.

Missouri is one of only a few states that prohibit advanced practice nurses from prescribing at least some controlled substances.

House Committee Advances Proposal On Organ Donation Standards

A bill advanced by a House Committee would revamp and update laws governing organ donation. Senate Committee Substitute for Senate Bill 1139 would codify a new version of the Uniform Anatomic Gift Act that has been approved by a national commission. The bill now moves to the full House for debate.

The model law is designed to eliminate obstacles to organ donation and procurement caused by inconsistent state laws. Missouri’s version of the Uniform Anatomical Gift Act has not been significantly revised since 1969. Missouri's two organ procurement organizations, along with the Missouri Department of Health and Senior Services and the Missouri Hospital Association support the bill. A companion bill, House Bill 2106, is advancing in the House.

An additional provision, added to the bill when the legislation was in the Senate, relates to coroners and medical examiners. This provision would revise current procedures for transferring bodies from one county to another county, designating death certificates, notification and investigation responsibilities, and determining what county should be considered the place of death. In addition, current law on coroners and medical examiners is amended to specify the investigation procedures to be used in deaths by homicide; suicide; accident; criminal abortion, including self-induced abortions; child fatality; or any unusual or suspicious manner.

Senate Panel Hears Amendment To Limit Annual State Spending

A Senate Committee held a hearing on House Committee Substitute for House Joint Resolution 70, a constitutional amendment that would limit annual state spending. If approved by the committee, the amendment will advance to the full Senate for debate.

The constitutional amendment would prohibit, upon voter approval, appropriations in any fiscal year from exceeding the total state general revenue appropriations from the previous year by more than the appropriations growth limit. The appropriations growth limit is defined in the measure as the greater of zero or the sum of the annual rate of inflation and the annual Missouri population growth.

For any fiscal year in which the net general revenue collections are in excess of 1 percent of the authorized net general revenue appropriations allowed, as determined in the previous formula, the excess is to be transferred in equal amounts to the Cash Operating Reserve Fund and the Budget Reserve Fund, which are created by the bill. Any revenue in excess of the specified limits of the funds would be refunded to taxpayers.

Total state general revenue appropriations would be allowed to exceed the appropriations limit only if the governor declares an emergency and the Missouri General Assembly approves appropriation bills to meet the emergency. The funds appropriated to meet the emergency would not increase the appropriation limit for the following fiscal year.

New or increased tax revenues or fees receiving voter approval will be exempt from the calculation of the appropriations growth limit for the year in which they are passed. There was short notice of the hearing and Senate Leadership was asked for another hearing next week.

Abortion Bill Heard by Senate Committee

A Senate Committee heard a proposal this week regulating abortion. House Committee Substitute for House Bill 1831 would require that abortions not be performed or induced without the voluntary, informed and uncoerced consent of the patient at least 24 hours before the abortion. The bill also revises the definition of "abortion" and requires an obstetric ultrasound be conducted before the 24–hour waiting period for an abortion. If approved by the committee, the bill would move to the full Senate for debate.

The bill also would create the crime of knowingly coercing a woman to seek or obtain an abortion. Such coercion includes committing or threatening to do the following.

• abusing or stalking the woman
• committing an offense against the woman or her family
• filing for divorce
• refusing to pay child support or provide financial support
• taking the unborn child once born or the mother's other children
• changing the woman’s house or existing residence
• discharging the woman from her employment
• revoking a scholarship awarded to the woman

Legislature Passes Pharmacy Rebates Bill

Senate Bill 1068 was passed by the Missouri House. The bill establishes the Pharmacy Rebates Fund for the purpose of depositing any revenues received by the state from pharmaceutical manufacturer rebates as required by state or federal law for use in the MO HealthNet pharmacy program. The bill has already been approved by the Senate. However, before moving to the Governor for his signature, the Senate must accept or reject changes made to the bill by the House.

The Department of Health has noticed that this rebate language would impact the "Ryan White HIV/AIDS rebates" and has asked that the conference committee "exceed the differences". They would like to add language "except for programs administered by DHSS". I will work with the DHSS to make this change.

Local Public Health Funding

As mentioned earlier this week, the Senate conferees via Senator Nodler Chair cut the $1.23 million recommended by the House for increasing funding for local public health.

Dr. Cooper was very displeased and had lobbied on MOALPHA's behalf. Your calls and contacts were very helpful.

However, Senator Nodler cut virtually everything that increased spending on the premise that next year he would have to cut "core" due to the economic picture.

Malpractice insurance: killing issue for midwife bill?

Time has about run out on Senator John Loudon's latest effort to give lay midwives professional standing in the eyes of the state. His last chance likely will come early next week. But late–rising concerns about who is financially liable if a home–birth goes badly wrong are the latest obstacle in his effort to gain state recognition for those midwives A potentially killing issue is lack of liability insurance for midwives. St. Joseph Senator Charlie Shields, who works in hospital administration at home, wants to keep hospital people from being sued because they try to save a baby and a mother when there are big problems with a home birth. "If nurse midwives could buy insurance, I would have no trouble with this," he says.

Shields suggests changing Loudon's bill to say anyone at a hospital or clinic who has to deal with the aftermath of a problematic home birth cannot be sued for anything they do in the first 48 hours after the mother and child arrive for emergency treatment. Loudon says that's bad public policy. Shields says he won't let the bill advance if his people don't have that protection.

Shields has that power. As Senate floor leader, he decides what bills can be debated.

Next Week

Only two weeks remain in the 2008 legislative session. Budget will need to be completed by the end of the week. This gives the legislature another full week to work on legislation which is both good and bad.

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