KYNA IMAN, LLC 124 East High Street P.O. Box 1483 Jefferson City, MO fax

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1 KYNA IMAN, LLC 124 East High Street P.O. Box 1483 Jefferson City, MO fax TO: MISSOURI NURSES ASSOCIATION FROM: Kyna Iman and Tricia Workman DATE: April 2, 2013 RE: Legislative Report MEDICAID TRANSFORMATION The House Government Oversight and Accountability Committee passed House Bill 700, sponsored by Rep. Jay Barnes, which makes changes to the requirements for delivery of health care benefits under the MO HealthNet program. The bill relies on a waiver from the federal government to cover only 100% of poverty level. States that expand adult Medicaid eligibility to 138 percent of poverty - an annual income of more than $15,800 for an individual - can receive full federal funding for the first three years, starting in After that, those states would pay a share that gradually increases to 10 percent by The bill was brought up for executive session in the House Government Accountability and Oversight Committee on Wednesday, April 3rd. The bill was voted "do pass" 7-2 as a House Committee Substitute. Some of the changes made include the addition of capitated payments, FRA protection, and a cancer carveout for women. An amendment was offered to raise the eligibility level to the federal requirement of 138 percent FPL, but was defeated. Rep. Barnes reiterated that he believed Missouri's chances were good at obtaining the necessary federal waivers needed for the reform provisions to take effect. Earlier Wednesday, Governor Nixon spoke to House Republicans on the Medicaid issue stating he was supportive of many of the provisions outlined in HB 700, however, stressed that it does not go far enough to qualify for full federal match funding. Senate Majority Floor Leader Ron Richard (R-Joplin) stated he felt lawmakers may need to create a committee to further investigate the issue before the next session, but expressed he did not see anything regarding this issue happening this session. Governor Nixon had recommended spending more than $900 million of federal funds to expand Medicaid coverage to an estimated 260,000 adults living either in poverty or slightly above it, as called for under President Barack Obama's health care law. But the Republican-led House refused to include the money in the budget, citing concerns about the future costs of a Medicaid expansion while pledging to keep working on an alternative.

2 All healthcare provider groups, chambers of commerce, business associations, etc. are working to pursue passage of some form of Medicaid transformation. However, at this time, there has been no movement from the House or Senate Republicans to adopt an exchange or include the federal funding in the state budget. APRN ACCESS TO CARE LEGISLATION: The House Professional Registration Committee passed House Committee Substitute for House Bill 314, sponsored by Rep. Lyle Rowland, by a vote of 16 to four with four absent. The legislation now goes to the House Rules Committee for a vote before advancing to the House floor for debate. The main difference in the substitute and the original House Bill 314, is the phase out or transition to practice for collaborative practice agreements. Since there was much testimony offered in the House and in the Senate hearings regarding education for physicians and residency requirements, we added language to the House Committee Substitute to address these concerns. For thirty-six months, an APRN would be required to work in a collaborative practice agreement with all the current guidelines EXCEPT THE MILEAGE. We completely eliminated the geographical proximity for all APRN s. After the three year residency, each APRN is accountable to patients, the nursing profession, and the board of nursing for having a written attestation for a safe mechanism for consultation, care coordination, or referral with a physician or other health care providers. Language is also included in the substitute to clean-up the MoHealthNet Chapter to state all Advanced Practice Registered Nurses can be reimbursed, not just pediatric or family nurse practitioners. Language from the Board of Nursing is also included to establish a separate APRN license instead of a document of recognition. The Senate Financial Government Committee heard Senate Bill 167, sponsored by Senator Sater, which is the same as the original HB314. On Thursday, the committee voted unanimously to support a Senate Committee Substitute, which is a very watered down version of our original bill. The physician groups lobbied strongly against any changes to collaborative practice agreements. In order to get the bill through the Senate and past Senator Schaaf, we agreed to the Senate Committee Substitute. The sub has the MoHealthNet clean-up and the third license for APRN s at the Board of Nursing. Now we are working to get the bills to the floor for further debate. MILEAGE BARRIER LEGISLATION: Senator Wasson and Rep. Burlison filed legislation on behalf of the Missouri Association of Rural Health Clinics to address the mileage barrier for APRN s in collaborative practice agreements. Senate Bill 330 and House Bill 625 have passed in their chamber of origin and will be crossing over to the other chamber. MONA testified for informational

3 purposes only on these bills because they allow APRN s to work 28 days out of the year without their collaborating physician being within the mileage requirements. While this helps keep the clinic open in the absence of the physician, it does not go far enough in totally eliminating the mileage requirement for APRN s. PRESCRIPTION DRUG MONITORING PROGRAM: The Senate Veterans Affairs and Health Committee heard Senate Bill 233, sponsored by Senator Sater, which would create a Prescription Drug Monitoring Program. Once again, Senator Schaaf is requesting the program go to the vote of the people of Missouri. Now, with the current concerns over the Department of Revenue collecting information on people who have their conceal and carry permits, Chairman Brown has not brought the bill up for a vote. New concerns over personal privacy and the creation of a database is beginning to be seen as more of a bad thing than a transparency issue. The House version, House Bill 347, sponsored by Rep. Engler, has not been referred to committee in the House for a hearing. BOARD OF NURSING DISCIPLINE ISSUES: The Senate has passed Senate Bill 370, sponsored by Senator Wasson, which was requested by the State Board of Nursing. This act provides that for certain causes the Board may request an emergency suspension or restriction of a person's license with the Commission. The act describes the process for the proceedings that the Board and the Commission must follow, and how many days the Commission has to answer the complaint and render a decision. If the Commission does not find probable cause and does not grant the emergency suspension then the Board must remove all references to the proceedings from public record. SAFE LIFTING LEGISLATION: House Bill 856, sponsored by Rep. Judy Morgan, requires hospitals to adopt a patient protection and health care worker back and musculoskeletal injury prevention plan. Rep. Morgan has been working with nurses and wants to help MONA pass this legislation for her constituents. The bill has been introduced; however, has not been referred to a committee for a hearing at this time. VOLUNTEER SERVICES LEGISLATION: The Senate has passed Senate Bill 129, sponsored by Senator Sater. This act establishes the Volunteer Health Services Act which allows a licensed health care provider to provide volunteer professional health care services for a sponsoring organization. A volunteer cannot receive any form of direct or indirect compensation, benefits, or consideration for his or her health care services. The volunteer shall perform acts within the scope of his or her professional license, in his or her professional practice area and in compliance with all applicable health care regulations. The bill has been referred to House Health Care Policy Committee for a hearing. MEDICAL MALPRACTICE LEGISLATION: The House has passed House Bill 112, sponsored by Rep. Burlison, by a vote of 93 to 62. This bill changes the laws regarding claims arising out of the rendering or failure to

4 render health care services by a health care provider. Currently, an action against a health care provider for rendering or failing to render health care services is a common law cause of action. The bill replaces the common law cause of action with a statutory cause of action for damages against a health care provider for personal injury or death arising out of the rendering of or failure to render health services. The elements of the statutory cause of action are that the health care provider failed to use that degree of skill and learning ordinarily used under the same or similar circumstances by similarly situated health care providers and that the failure proximately caused injury or death. While the bill passed with 93 votes to pass over to the Senate Chamber, if passed and vetoed by the Governor, the House would need 109 votes to override the Governor s veto. The Senate version has been having difficulty getting voted out of Senator Dixon s Committee on Judiciary. The House version was referred to the Senate Small Business Committee in the Senate, and a hearing is scheduled for Tuesday, April 9. TELEHEALTH LEGISLATION: Rep. Kathy Swan, sponsored House Bill 936, which establishes the "Utilization of Telehealth" by advanced practice registered nurses in certain rural areas. The legislation would set up a pilot project in a rural area to allow APRN s to utilize telehealth to care for patients without mileage restrictions and other barriers to care. The bill was just introduced and has not had a hearing at this time. Senator Kiki Curls, sponsored Senate Bill 262, which prohibits health carriers from denying coverage for a health care service on the basis that the service was provided through telemedicine if the same service would be covered when delivered in person. The Senate passed the legislation and it is now on its way to the House for further action. MENTAL HEALTH LEGISLATION: Senate Bill 178, sponsored by Senator Schaaf, and House Bill 724, sponsored by Rep. Jeanne Kirkton, relates to mental health facilities. Under current law, physical or chemical restraints, isolation, or seclusion cannot be used on patients, residents or clients of a mental health facility or mental health program unless it is determined by the head of the facility or the attending licensed physician that it is necessary to protect the health and safety of the individual or others and that it provides the least restrictive environment. This act allows such orders to also be made by the attending advanced practice registered nurse in a collaborative practice arrangement with the attending licensed physician. The Senate passed the Senate version and it has been sent to the House, and has been referred to the Committee on Health Care Policy. Senator Schaaf added the following provision that is not included in Rep. Kirkton s House version. All orders made by the attending advanced practice registered nurse under this act shall be reviewed in person by the attending licensed physician of the facility within 24 hours or the next regular working day of the order being issued, and such review shall be documented in the clinical record of the patient, resident, or client. The attending advanced practice registered nurse shall also document the use of the restraint, isolation or seclusion.

5 MISSOURI FOUNDATION FOR HEALTH: Rep. Keith Frederick has introduced House Bill 608, which requires the MO HealthNet Division to establish a pilot program implementing an electronic benefit transfer payment system for receipt of MO HealthNet services by participating recipients. While MONA does not oppose the intent of the pilot project, MONA does oppose the funding source. Frederick would allow the legislature to divert funding from the Missouri Foundation for Health, who funds numerous non-profit organizations and programs for Missourians. The bill was referred to Rep. Frederick s committee on Health Care Policy; however, he has not scheduled a hearing on his own bill. MONA and numerous other non-profits launched a major campaign against the bill early in session. PHYSICIAN ASSISTANT LEGISLATION: Senator Sater has introduced Senate Bill 219, and Rep. Frederick introduced House Bill 387, which would modify provisions relating to the scope of practice for physician assistants. Both Chambers have heard the bills; and the House Professional Registration Committee has voted the bill out do pass. The House version is waiting to go through the House Rules Committee prior to going to the floor for full debate. The Senate version was voted out of Senate Financial Government Committee on Thursday. MOTORCYCLE HEADGEAR LEGISLATION: Rep. Delus Johnson, sponsored House Bill 341, specifies that the requirement that every person operating or riding on a motorcycle on any state highway wear protective headgear will not apply from August 1 through August 21 of each year. The bill was heard in House General Laws; however, has not had a vote on the bill. PUBLIC SAFETY LEGISLATION: Rep. Dave Hinson, sponsored House Bill 335, which relates to a variety of public safety issues. One provision MONA is watching allows a person to be eligible for certification by the Department of Health and Senior Services as a community paramedic if he or she is currently certified as a paramedic and has two years of full-time service or its part-time equivalent; successfully completes a community paramedic certification program from a college, university, or educational institution that has been approved by the department or accredited by a national accreditation organization approved by the department; and completes an application form. A community paramedic must practice in accordance with protocols and supervisory standards established by the medical director and may provide services of a health care plan if the plan has been developed by the patient's primary physician, advanced practice registered nurse, or physician assistant and the patient isn't receiving the services from another provider. These are the issues that are priorities for MONA. Please let me know if you have any questions or comments. Thank you for the opportunity to represent MONA at the State Capitol.

Missouri Academy of Family Physicians (MAFP) Legislative Update - January 18, 2015 By Pat Strader, Legislative Consultant for MAFP

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