Ohio Health Policy Update. Jeffrey S. Smith, JD, Director, Government Relations

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1 Ohio Health Policy Update Jeffrey S. Smith, JD, Director, Government Relations

2 Managed Care Reforms

(currently 2 years) Prohibit retroactive denial for payment of services that have been prior

3 Administrative Simplification SB 136 Health Insurance Modernization Act Prohibit unilateral contractual amendments Prompt pay law to 15 Days (currently 30 days) Limit take backs to 6 months (currently 2 years) Prohibit retroactive denial for payment of services that have been prior authorized Greater transparency of prior authorization requirements Copyright 2012 Ohio State Medical Association 3

4 Physician Ranking Programs SB Physician Ranking Programs Establish standards for physician rating programs and tiered networks Based on the NY AG Settlement Standards Prohibit rankings based solely on cost-efficiency Use nationally-recognized, evidence-based guidelines for quality measurements Use accurate, adequate and risk-adjusted data samples Transparency of data methodologies 45-day advance notice to physician regarding evaluation Compliance oversight by independent monitor or ODI Copyright 2012 Ohio State Medical Association 4

5 Anthem Steerage Program Program to direct or steer patients to lower cost providers for diagnostic tests and imaging procedures. Referrals are driven by economics versus patient safety and quality measures. Copyright 2012 Ohio State Medical Association 5

6 Anthem Steerage Program Referring physician is not notified of the switch to the lower cost provider Duplicate tests may need to be ordered Images are of poor quality and expose patients to more radiation with duplicate tests Reports need to provide accurate, definitive diagnosis Copyright 2012 Ohio State Medical Association 6

7 Public Health

8 Public Health Smoking and Tobacco Use Protect Ohio s indoor smoking ban Seek funding for tobacco prevention efforts Obesity Continue to support efforts to make nutritional information more transparent Protect law on BMI data collection by schools Cancer Oral chemotherapy parity with IV chemotherapy SB 194 Prohibit minors from using tanning beds HB 119 Copyright 2012 Ohio State Medical Association 8

9 Prescription Drug Abuse

10 Prescription Drug Abuse Epidemic 4 Ohioans per day die due to unintentional drug poisoning In Scioto County, every man, woman and child receives 126 doses of Oxycontin per year 56% of people abusing prescription drugs receive them from a friend/relative Ohio physicians dispensed more dosages of Oxycontin than IN, PA, KY, WV and MI combined. Copyright 2012 Ohio State Medical Association 10

11 HB 93 The Pill Mill Bill Sponsored by a Physician and Pharmacist Introduced 2/8/11 and Enacted 5/20/11 Approved Unanimously by the General Assembly with an Emergency Clause Effective Immediately Copyright 2012 Ohio State Medical Association 11

12 HB 93 - Overview Licensure of Pain Management Clinics Primary component of practice is treating pain or chronic pain and >50% of patients are prescribed controlled substances Restrictions on In-Office Dispensing of Controlled Substances May not dispense more than a 72 hour supply and no more than 2,500 dosage units per month Establishes a Medicaid Pharmacy Lock-in program Establishes a Drug Take Back Program Copyright 2012 Ohio State Medical Association 12

13 Ohio Automated Rx Reporting System Physicians must register with OARRS to search for patient information using a combination of name, birth date, and ZIP code. Provides Ohio patients prescriptive history for Rx filled in pharmacies. Provides the name of prescribing physicians and the filling pharmacies. Effective Tool, but some limitations- Information is not instantaneously available; lag time between filling Rx; Does not monitor prescriptions filled in a federal facility (VA or military hospital); Does not interface with EHR or e-prescribing systems. Copyright 2012 Ohio State Medical Association 13

14 OARRS Review Authorizes the Medical and other regulatory Boards to establish rules on OARRS Review Allows for a prescriber s registered agent to request information from OARRS Establishes criminal penalties for misusing OARRS information Current Rule: Physician must access and document OARRS review if they have reason to believe patient has a history of abuse or is abusing, or; After 12 weeks of treatment and annually for patients receiving controlled substances on a protracted basis (in excess of 12 weeks) Copyright 2012 Ohio State Medical Association 14

15 Scope of Practice

16 Scope of Practice I can pretty much do everything I can pretty a physician much do can everything do, and a I physician see more can patients. do, and I see more patients J. Thomas, Nurse Practitioner J. The Thomas, Columbus Nurse Dispatch Practitioner The Columbus Dispatch Physician Led Health Care Teams APN & PA Rx Schedule II CRNA Rx authority Psychologists Rx authority Pharmacists prescribing by protocol Copyright 2012 Ohio State Medical Association 16

17 Medical Education

18 Support for Medical Education Enhancing the Ohio Physician Loan Repayment Program Choose Ohio First Scholarships for Primary Care Physicians (HB 198) Support for Continued Federal Funding of Graduate Medical Education OSMA Health Policy Fellowship Program for Medical Students Copyright 2012 Ohio State Medical Association 18

19 Regulatory Issues

20 Maintenance of Licensure The State Medical Board is considering Ohio as a pilot state in the FSMB Maintenance of Licensure (MOL) pilot project. Ohio will be one of 11 states considering enhanced MOL standards for licensees. The enhanced MOL standards are intended to build upon the current requirement of 100 CME hours every two years and include several components: 1. Reflective Self-Assessment (What improvements can I make?) 2. Assessment of Knowledge and Skills (What do I need to know and be able to do?) 3. Performance in Practice (How am I doing?) False Claims Act SB 143 Creates new penalties for submitting fraudulent claims. Fraud could include mistakes. Copyright 2012 Ohio State Medical Association 20

21 State Implementation of the Affordable Care Act

23 ACA Impact on Ohio Medicaid eligibility to 138% FPL beginning 1/1/2014 Expands eligibility to 1.6 million individuals; 916,000 expected to enroll Cost to Ohio: $1.45 billion (2013 to 2019) Cost to Federal: $16.94 billion (2013 to 2019) Copyright 2012 Ohio State Medical Association 23

24 State Implementation of the ACA Medicaid Eligibility Expansion to 138% FPL Will Ohio Expand Medicaid eligibility? Health Insurance Exchange State or Federal Exchange? Accountable Care Organizations (ACOs) Four Ohio Health Systems participating in the Medicare Shared Savings Program- UH 1,770 physicians Summa 612 physicians ProMedica Physician Group 250 physicians Mercy Health Select 365 physicians Copyright 2012 Ohio State Medical Association 24

25 Medicaid

26 Medicaid Reform Ohio Medicaid will merge the current eight service regions into three regions. Coverage for the CFC and ABD populations will be combined into a single contract in each region. Earlier this year, Ohio Medicaid announced the selected managed care plans to provide service to Ohioans enrolled in Medicaid beginning January 1, The new plans are: CareSource Buckeye Community Health Plan Molina Healthcare of Ohio Paramount Advantage United Healthcare Community Plan of Ohio Copyright 2012 Ohio State Medical Association 26

27 Medicaid Reform Plans will be required to develop incentives for providers that are tied to improving quality of care and health outcomes. Current MCOs working in the state that did not make the cut include: Amerigroup Ohio Wellcare of Ohio Ohio s Medicaid MCO program currently serves 1.7 million individuals Copyright 2012 Ohio State Medical Association 27

29 Medicare

30 Medicare Sustainable Growth Rate (SGR) 32% cut in Medicare fee scheduled for Jan. 1, Flawed SGR comes with a hefty price tag - $300 Billion+ for permanent fix, $40 Billion+ for another band aid. AMA and national specialties to develop new strategy Copyright 2012 Ohio State Medical Association 30

31 Seniors Deserve the Freedom to Choose their Doctor The Medicare Patient Empowerment Act can make choice a reality 1) Sign online petition at 2) Ask your representative to help America s senior by cosponsoring H.R ) Ask your senators to co-sponsor S Copyright 2012 Ohio State Medical Association 31

32 Medical Liability

33 Medical Liability 20 tort reforms enacted since 2004 Philosophical view of the Ohio Supreme Court SB Liability protection for EMTALA and disaster medical care Dual Agency Residency Training Billed charges vs. amount paid Affidavit of Merit Modifications Copyright 2012 Ohio State Medical Association 33

36 2012 Elections

38 Ohio Supreme Court The philosophical balance of the Ohio Supreme Court is in jeopardy this election Order OSMAPAC Supreme Court Endorsed Candidate Posters and mock Rx Pads from OSMA office at (614) or Copyright 2012 Ohio State Medical Association 38

Managed Care Reforms. Ohio Healthcare Policy and Political Update. Physician Ranking Programs SB 121 - Physician Ranking Programs

Managed Care Reforms. Ohio Healthcare Policy and Political Update. Physician Ranking Programs SB 121 - Physician Ranking Programs Ohio Healthcare Policy and Political Update Jeffrey S. Smith, JD, Director, Government Relations Managed Care Reforms Administrative Simplification SB 136 Health Insurance Modernization Act Prohibit unilateral