Patient Protection
​and Public Health Advocacy
​Patient Protection
 
Anthem Prudent Layperson
  • The impetus for this 2018 legislation was Anthem’s decision to begin denying emergency room claims.  This policy redefined the prudent layperson standard so that Anthem could make payment decisions based on the patient’s final diagnosis rather than their initial symptoms.  In addition, Anthem was set to begin a policy of reducing payments by 25% for same day services when they were accompanied by an E/M code and a modifier-25.  Due to pressure from MSMA, Anthem rescinded this policy in the early spring.
  • Missouri’s prudent layperson standard is found in the statute that defines emergency medical condition.  To address Anthem’s move, the definition was changed to make sure that covered emergencies weren’t dependent upon the patient’s final diagnosis.  As long as the patient’s symptoms were of sufficient severity, the prudent layperson standard will be met.  In addition, we included language that made the emergency physician the sole determiner of when the patient was stabilized.  Anything prior to stabilization doesn’t require prior authorization.
  • If an insurer denies a claim based on the absence of an emergency medical condition, the insurer must review the medical record.  That review must be completed by a board-certified physician licensed to practice medicine in Missouri.  Language was also included that allows for direct payment to the provider for services necessary to screen and stabilize out-of-network patients, as well as post-stabilization services authorized by the insurer.
  • Similarly, another section of the bill requires insurance carriers to make payments directly to out-of-network providers for any health care services that the carrier has authorized the patient to seek out-of-network, as long as the patient’s plan does not already include an out-of-network benefit.
  • The final major section of the bill dealt with surprise billing.  This wasn’t an issue we expected to tackle this session, but the need to enact some level of consumer protection was an overriding concern in the Senate.  No other section of the bill demanded as much of our time as the prohibition against surprise billing.
  • The new law only applies to patients who present at an in-network facility with an emergency medical condition, and applies to out-of-network physician services provided to them until they are discharged.  Physicians may choose to send a claim for charges to the patient’s insurance company within 120 days of providing the service.  Within 45 days of receiving that claim, the insurance company must offer to pay the physician a reasonable reimbursement rate.  If the physician participates in any other networks offered by that insurer, the reimbursement offer will be the amount from the network that has the highest reimbursement.
  • If an agreement is not reached in the negotiation period, the law requires the Department of Insurance to ensure access to an arbitration process.  The arbitrator is restricted to determining the reimbursement in a range between 120% of Medicare and 70% of usual and customary rate as determined by an independent database, and the arbitrator must take certain factors into account, such as the physician’s skill and training, the physician’s usual charge for the service, and the complexity of the case.
  •  All in all, we believe we have passed a solid insurance reform law.  This was a huge legislative win for MSMA, the health care community, and patients from all over Missouri.  With the exception of the surprise billing provision, the law will go into effect on August 28, 2018.  The surprise billing section takes effect on January 1, 2019.  We would be remiss if we didn’t mention the hard work and dedication of Sen. Bob Onder, M.D., Sen. Jill Schupp, Rep. Mike Henderson, and Sen. Paul Wieland, in assisting us in making sure these important reforms were successfully passed this year.
 
Increased Opioid Treatment
  • MSMA is dedicated to exploring new ways to stem the tide of the opioid epidemic.  Curbing the supply of opioids through prescribing limitations and enforcement actions only addresses a portion of the complex problem.  Increasing access to treatment for substance abuse and addiction must also be addressed.  The Improved Access to Treatment for Opioid Addiction Act (IATOA), passed in 2018, included a number of provisions to bolster the state’s ability to provide treatment.  It allows mid-level providers to prescribe a thirty-day supply of buprenorphine for substance abuse treatment under the direction of a supervising physician.  It also requires insurers to offer coverage for medication-assisted-treatments, and eliminates the exclusion of chemical dependency from the definition of mental health condition.  This effectively mandates coverage for addiction.  The legislation increases the availability of addiction resources to mid-level providers in rural areas of the state, and loosens some supervisory requirements in order to enhance access to treatment.
 
Prescription Drug Take Back
  • MSMA supported this popular legislative provision, which was passed in three separate bills in 2018.  The legislation allows unused controlled substances to be accepted from the public through collection receptacles provided through drug take back programs sponsored by a DEA-authorized collector (like Walgreens, CVS, law enforcement agencies, etc.).  The public can deposit their unused prescription drugs in the receptacles regardless of whether or not the authorized collector originally dispensed the drug.  Improving public access to secure drug disposal boxes is an easy way to safely dispose of unused opioids and other prescription drugs that would otherwise sit in medicine cabinets and risk being abused or diverted.  The measure also requires the Department of Health and Senior Services to develop an education and awareness program about drug disposal by August 2019.
 
Postpartum MO HealthNet Benefits
  • MSMA was pleased to support a 2018 measure that expanded substance abuse treatment coverage for postpartum women in Missouri.  Currently, certain pregnant women receiving MO HealthNet benefits continue to be eligible for all pregnancy-related and postpartum benefits for 60 days following the last day of their pregnancy.  Under this act, pregnant women receiving substance abuse treatment within 60 days of giving birth will be eligible for MO HealthNet benefits for substance abuse treatment and mental health services related to substance abuse treatment for 12 additional months, as long as they remain adherent with treatment.  Many legislators expressed hope that expanded access to substance abuse treatment will help new at-risk mothers keep their children in their home and ease the burden on the state’s foster care system.  The bill is subject to appropriations and federal approval.
 
Generic Substitutions
  1. MSMA supported legislation in 2018 that created more flexibility for pharmacists when dispensing prescriptions.  The measure permits a pharmacist who receives a prescription for a brand name product to select a less expensive generically equivalent product unless the patient specifically requests the brand name drug, or the physician indicates that substitution is prohibited.  In other words, rather than sign a “dispense as written” line on the prescription pad, a physician will need to write “DAW” or “do not substitute” on the script.  The bill doesn’t affect prescriptions that are called into the pharmacy.
 
Mental Health Parity
  1. MSMA supports legislation that would prohibit insurance companies from imposing certain treatment limits on mental health benefits in a more stringent manner than they are applied to surgical or medical benefits.  There was a lot of support for this legislation in the early stages of the legislative process in 2018, but the insurance companies were able to stall until time ran out and it never received any floor debate. We expect we’ll see this legislation again in future legislative sessions, and we will continue to support providing quality access to mental health care for Missouri citizens.
Public Health
 
Immunizations
  • Legislation was passed in 2018 that lowered the minimum age of patients which can receive immunizations at pharmacy under a written protocol authorized by a physician.  Pharmacists will now be able to give statutorily allowed vaccinations to patients as young as seven in accordance with Centers for Disease Control recommendations.  No new immunizations were allowed, and with the exception of viral influenza, only three vaccinations are on the CDC schedule between the ages of seven and twelve.  The language also contains a requirement that all pharmacy-administered vaccinations be entered into the state’s ShowMeVax database, which allows physicians to track a patient’s immunization history.
 
Texting While Driving Prohibition
  1. Legislation that would ban texting and driving has struggled for years to get the attention and support it deserves in the Capitol.  Several 2018 bills would have created a statewide ban on texting while driving, but they unfortunately ran into staunch opposition from a vocal group of legislators.  Our present law allows drivers over 21 years of age to text and drive, despite a lack of scientific evidence to support an age of prohibition. Only two other states don’t currently outlaw this behavior, and the other 47 states have a complete ban on texting and driving.  We expect the bill to be proposed once again next year, and MSMA will continue supporting this legislation to make our roadways safer.
 
Tanning Bed Prohibitions
  1. MSMA joined a broad coalition of healthcare organizations to support this legislation in 2018, which would have put an end to teen tanning bed use in Missouri.  Under current state law, a child under 17 years of age must obtain parental consent before they can use a tanning bed or other tanning device.  The legislation would have prohibited anyone under the age of 18 from using a tanning bed.  It also would have required a trained employee to be present at a tanning facility during operating hours to assist customers and offer information about proper tanning device usage.  Though countless dermatologists and skin cancer survivors offered compelling testimony in support of the legislation, several vocal legislators felt that the bill would infringe upon their personal freedom and the bill did not pass.
 
Motorcycle Helmet Laws
  • MSMA has butted heads year after year with a group of motorcyclists who argue that they should not have to wear helmets while riding on the state’s roads and highways.  Legislation proposed in the Capitol would limit the statewide helmet mandate to riders under 18 years of age and to those who have been issued an instruction permit.  Fully qualified operators 18 and older would be allowed to ride helmetless as long as they could provide proof of a $1 million medical payment insurance policy.  MSMA opposes legislation that would remove the helmet mandate for motorcyclists and will continue to oppose such bills in the upcoming legislative session.
 
PDMP – St Louis County and Missouri Legislature
  • 2018 was a quiet year for prescription drug monitoring program (PDMP) legislation.  Rep. Rehder and Sen. Schatz continued to carry the torch for a statewide PDMP, but the bill ran into the same obstacles in the legislature that have been present for the past several years.  We expect the legislature will pick up the issue again next year but until then, the St. Louis County PDMP continues to cover almost 80% of the state’s patients and 92% of the state’s prescribers.  We continue to advocate that comprehensive PDMPs like the one in St. Louis are effective tools for physicians to use to combat the opioid epidemic and improve treatment for patients with substance abuse disorders.
 
STEMI/TCD
  • Governor Parson’s 2018 veto of a budget line item that funded Missouri’s Time Critical Diagnosis (TCD) program has caused great concern for physicians and hospitals around the state.  Our TCD system ensures patients receive fast, appropriate care for critical medical events like trauma, strokes, or heart attacks.  With this line item veto, the functionality of our TCD system has been thrown into jeopardy.  This negatively affects patients around the state, particularly in rural communities where hospitals are far apart and timely care is essential for a patient’s survival and recovery.
  • During a House Budget Committee hearing following the veto, lawmakers and members of the health care community made their frustration known to the Department of Health and Senior Services.  Following this hearing, a coalition of medical societies and health care health care organizations from around the state pledged to collaborate with Missouri state government to maintain and enhance our TCD system.  MSMA and many other organizations like the Missouri Hospital Association appreciate policymakers’ universal acknowledgement of the value of a system of care to promote time-sensitive treatments of stroke, STEMI, and traumatic injuries.  The TCD system improves patient outcomes, and MSMA will continue to fight for its continuation.