New Leadership at the Capitol
In some circles, it’s still hard to believe—a Democratic supermajority in Lansing for the first time in nearly 40 years. Not only is one party in charge of the governorship and both houses of the Legislature, but just under half of the members of the state House are serving as lawmakers for the first time.
Nearly half in the Michigan House of Representative—54 of 110 members—are serving for the first time.
The slimmest of margins separate the caucuses that will lead the development and approval of new laws this year. A 56-54 House split means just one vote across party lines shifts the balance. In the Senate, the fault line also rests on one vote, as Democrats hold a 20–18 edge.
MSMS will pick up with many of the same policy challenges as last session, but with the additional burden of educating new lawmakers on the many complex issues affecting the practice of medicine. Scope infringement, staff shortages, Medicaid uplift and emerging public health threats will create the bulk of our advocacy work this year, and even that list is far from exhaustive.
All of these concerns are set against the backdrop of an unspent $9 billion surplus—yes, billion with a B—which means that MSMS has cultivated some budget-specific asks in addition to our list of legislative priorities.
Collectively and individually, physicians across the entire state must engage with lawmakers to protect and promote the policies that best serve patients. Working together, physician perspectives can help bring about the pragmatic, sensible policy changes that will benefit patients and public health alike.
Just look at all we’ve accomplished during the last year alone:
> Prior Authorization Reform
It’s hard to believe it’s been almost a year since we secured a hard-fought victory in prior authorization reform. As an organization, we knew the prior authorization process was broken, so we worked to craft legislative solutions that would reduce wait times and streamline how physician offices and payers interact. Our goal? Reducing endless paperwork and ultimately improving access to care for patients.
More than three years of lawmaker education and physician advocacy proved fruitful when Gov. Whitmer signed SB 247 on April 7, 2022. Many of the reforms take effect this June, when insurers will be required to make available a standardized electronic prior authorization request transaction process.
Under the new law, urgent requests are managed much more easily, with the prior authorization considered granted if the insurer fails to act within 72 hours of the original submission. Transparency, clinical validity, and fairness embedded in the reforms will ensure patients receive timely coverage decisions and life-changing care.
MSMS’s work in this space is not done. Reduction of one administrative burden of practice frees up more time for patient care, but there are countless other encumbrances imposed by insurance companies that will require continued advocacy to reduce.
“Today’s action by Gov. Whitmer to sign this overwhelmingly bipartisan legislation will directly help patients across Michigan,” said state Senator Curt VanderWall, R-Ludington. “This new law reforms the prior authorization process, which has created barriers and inefficiencies with access and quality of care in the health care system. It will promote transparency of practices used by insurers, allowing enrollees and health care providers to be fully informed while making coverage and care decisions.” – April 2022
> Approval of bills to reduce administrative practice burdens is a huge success for physicians, but last term MSMS also successfully batted back several measures that would have interfered on scope of practice and overly burdensome Continuing Medical Education (CME) requirements.
A Senate bill was introduced to allow nurse practitioners to practice independently, including prescribing authority for opioids and other medications. The bill was referred to the Senate Committee on Health Policy and Human Services but did not receive a hearing. While the independent practice legislation was thwarted, we anticipate the possibility of similar bills being reintroduced this session. Advocating for a physician-led health care model is the top public policy priority for MSMS. Protecting the scope of practice is critical if we are serious as a state about providing quality, safe accessible and affordable care for patients. Whether it is nurse practitioners, anesthesia care or another infringement that eradicates the core work of a physician, MSMS must continue to diligently protect the work physicians are trained to do better than anyone else.
Legislation that would have required all physicians to take a course to identify and treat lead poisoning in children as part of their continuing education for license renewal did not move forward, but we also expect a lead remediation bill package to be introduced again, with the CME requirement just one part of it. MSMS opposes any attempt to introduce compulsory content of mandated CME in the state of Michigan.
2023: Expect the Unexpected
New lawmakers, new leadership, and a majority that’s reached the pinnacle of power for the first time in 40 years—an unrelenting legislative session has begun. Public health is certain to be a priority, as are emerging public health issues, such as gun control. The MSMS legislative advocacy team is preparing for nearly every proposal imaginable, including the sleeping giant of health policy: tort reform.
The Scope of the Scope
While independent practice for NPs didn’t move toward the finish line last year, MSMS is aware that this legislation is likely to see another push this term.
Advocacy efforts must emphasize the critical importance of physician-led, team-based health care for Michigan patients and oppose independent prescriptive authority by non-physicians.
The immunization of children and adults as prophylaxis against infectious diseases is best performed at the direction of physicians involved in continuing care of the individual, considering the risks and benefits accruing to that individual. Guidelines and schedules produced by scientific groups and/or governmental agencies, while often helpful, should not be regarded as overriding the exercise of informed decision-making by the physician where the welfare of his or her patient is involved.
“With the new majority in Lansing, we predict a larger focus on public health threats, such as lead remediation, other chemical contaminants such as PFAS, and gun violence. While partnering with legislators on these issues, it’s also incumbent upon us as an organization to raise up the voices of physicians who will emphasize the critical importance of physician-led care and individualized patient relationships.”
– Kate Dorsey, Manager of Federal and State Government Relations, MSMS
We’re halfway there! With prior authorization reform going into effect this year, we’ve reduced some of the lengthy red tape that obstructs and delays physician-recommended patient care. The next frontier of policy that reduces barriers in patient care is step therapy reform. Currently, insurance companies require a “fail first” approach to formulary treatments, harming patients and undercutting the physician-patient relationship. If we as physicians are to emphasize clinical expertise over cost-first policies, we must preserve and protect our rights as health care providers to make treatment decisions that favor the patient, not the payer.
MSMS favors reforms to the step therapy process that are based on well-developed scientific standards and administered in a flexible manner that considers the individual needs of patients. Any new state policy should require health insurers to base step therapy protocols on appropriate clinical practice guidelines or published peer reviewed data developed by independent experts with knowledge of the condition or conditions under consideration.
One of few positive benefits of the COVID-19 pandemic has been the move toward telehealth as a mainstream medical practice. Telehealth has proven to be an important care delivery method for improving access in underserved communities, particularly rural areas, areas with physician shortages, and areas with limited access to primary care services. The accessibility afforded by this technology benefits not just individual patients, but also scores points in public health generally through the elimination of barriers.
To ensure continuity of care and minimize the spread of COVID-19, physician practices quickly adopted telehealth during the pandemic. Payers also temporarily removed some of the regulatory and administrative barriers that were limiting telehealth use and payment of telehealth services, including payment at in-person rates during the public health crisis. However, payments are now reverting to pre-pandemic rates, and MSMS believes the time is right to make these equitable policies permanent given that telehealth is, and will continue to be, an effective method of health care delivery.
The biggest barrier to long term implementation of telemedicine services by providers is costs. Telehealth parity will encourage the growth of telemedicine and allow physicians to make investments to offer telemedicine services to patients.
With payers returning to pre-pandemic rates, legislation is needed that will require insurers to cover and reimburse telehealth services the same as if the service were provided in-person.
MSMS will pursue bills that:
- Require payment parity for telemedicine services as compared to the same service provided in person.
- Prohibit annual or lifetime limits on coverage for telemedicine.
- Prohibit prior authorization requirements on telemedicine that exceed requirements for the same in-person service.
- Prohibit insurers from placing certain restrictions/requirements on telemedicine services and providers.
- Allow insurers to require telemedicine services comply with the same coding, documentation, and other requirements necessary for payment as in-person service.
- Require that telemedicine services conform to the standards of care applicable to the provider’s profession and specialty.
A State Budget with Solutions
The latest figures on Michigan’s state budget surplus show that the balance of federal funding remains in the billions. Deciding how to allocate this immense amount of funding in ways that directly improve the lives of Michigan residents will be among the foremost challenges facing legislative leadership this year.
One of the budget goals identified by MSMS has a proven track record of success: Medicaid uplift. When the Affordable Care Act required states to increase Medicaid payments for primary care services to match Medicare payments at 100 percent, the increased payment rates improved access to care according to data from that time period. One study showed the availability of primary care appointments for Medicaid patients increased by 7.7 percentage points after Medicaid payments were raised.
The COVID-era policy that created the temporary Medicaid uplift helped alleviate the financial instability of physician practices that provide essential care to Medicaid patients.
Medicaid reimbursement rates remain far below Medicare and private insurance. These low rates, combined with increasing Medicaid enrollment, exacerbate the financial instability of physician practices that provide essential care to Medicaid patients. Primary care services and wellness checks contribute greatly to not just overall patient health, but cost savings in these programs for the state and federal governments.
MSMS has suggested budget language that states: the department shall provide Medicaid reimbursement rates for primary care services at the greater of either the actual rates paid during the previous fiscal year or at least 95 percent of the Medicare rate received for those services on the date the service is provided.
As the health care community is aware, the staffing shortage in Michigan is reaching acute levels. State government can play a part in alleviating a care crisis by creating a physician practice staff recruitment and training grant program. MSMS will seek funds from existing federal COVID funding grants to allocate to physician-owned practices in the acute, post-acute and behavioral health care space. Additionally, MSMS will seek opportunities for further uplifts in the Medicaid space, similar to the one secured for primary care services.
Senate Health Policy Chair: Sen. Kevin Hertel (D-St. Clair Shores), previously served 3 terms in the House of Representatives and worked in legislative affairs at Blue Cross Blue Shield.
House Health Policy Chair: Rep. Julie M. Rogers (D-Kalamazoo), a practicing physical therapist.
Spotlight issues: Lead poisoning prevention, reproductive freedom, Medicaid work requirements repeal.
The Democratic majority also announced the addition of the new Health Policy Behavioral Health Subcommittee, chaired by state Rep. Felicia Brabec (D-Pittsfield). Brabec is a practicing clinical psychologist with a master’s degree in clinical social work, with over two decades of experience.
Senate Appropriations Chair: Sen. Sarah Anthony (D-Lansing), previously served 2 terms in the House of Representatives.
House Appropriations Chair: Rep. Angela Witwer (D-Delta Township), in her third term in the House of Representatives, worked for 22 years at Sparrow Health System in clinical health care and then community relations.
The Frontlines of Public Health: Gun violence
As gun violence increasingly becomes part of our everyday lives and less of an isolated occurrence, the MSMS Board has reviewed the role of physicians and MSMS in addressing violence prevention. The Board last year hosted robust discussion on violence as a public health issue and emphasized the importance of promoting evidence-based solutions to understand what factors protect people or put them at risk for experiencing or perpetrating violence. The Board also reviewed the extensive policy on firearm safety adopted by the MSMS House of Delegates over the years.
With Democrats fully in charge of enacting new laws, it’s certain a gun control bill package will see legislative action this year. In Governor Whitmer’s State of the State address on January 26, she stated: “Let’s enact universal background checks for people who want to buy firearms. Let’s enact safe storage laws so we can make sure firearms are stored safely at home. And let’s enact extreme risk protection orders, so we can keep guns out of the hands of those who might represent a danger to themselves or others.”
The following are existing MSMS policies on gun violence and firearm safety issues:
- Education and training on gun safety, including requirements for firearm safety certifications.
- Strategies to increase firearm safety and prevent firearm injury and death.
- Evidence-based research on gun-related injuries and deaths.
- Bans on look-alike toy guns and the sale of assault weapons and large-capacity ammunition magazines.
- Policies prohibiting acquisition of firearms by high-risk person and limits on the ownership and use of assault weapons.
- Effective controls on the assembly, manufacture, distribution, and possession of handguns.
The exact parameters of any proposals are yet to be seen. MSMS’s Government Affairs team will closely monitor movement of the legislation and send key updates to our membership.
Other Items We’re Screening:
Torts: The Michigan Legislature has enacted four waves of tort reform legislation over the past four decades: 1986, 1993, 1995, and 2013. With full Democratic control of the Legislature, it’s a definite possibility that tort reform could be revisited. It’s likely that such a proposal would seek to increase the cap on non-economic damages plaintiffs can receive from providers. MSMS will work with lawmakers and other stakeholders to preserve Michigan’s existing tort reforms and retain existing legislative intent to ensure Michigan physicians may continue practicing medicine without fear of significant economic loss.
Filter First: We will continue to push for filter installation on daycare and school drinking fountains, negating the need to test and replace before adding filters. Presently, Michigan relies on the “test and tell” method to look for the presence of lead in drinking water, which only confirms the presence of lead without reducing exposure. Bypassing this inefficient method by simply installing filtered water drinking stations will ensure children have cleaner drinking water, sooner.
Reproductive health care: As during the overturn of Roe v. Wade and the ensuing political battles, MSMS will continue to oppose any criminalization of reproductive health treatments or procedures, and support repeal of the 1931 statute that criminalizes such medical treatment.
MSMS also supports collaboration with pharmacists to offer hormonal birth control over the counter.
In sum, the legislative agenda is packed. Just months into the new term, lawmakers are making major budget allocations, changing the tax structure, and looking at education reforms. At MSMS, we have our work cut out for us. As the complex issues before us grow in nature and number, so does our commitment to our advocacy work.
Onward we go, with a united voice, to lift up physician-led care.