The first eight months of 2023 saw a flurry of legislative activity in Lansing, as the newly elected Democratic majorities in both chambers of the Legislature took office and began their work. Governor Whitmer also began her second and final term as Governor at the beginning of 2023. This is the first time in 40 years that Democrats have controlled both the Governor’s office and both chambers of the Legislature. Needless to say, the list of policy priorities was long, and they wasted no time getting to work.
This report provides an overview of the significant health care legislation that MSMS has focused on this year. Our top priorities have been to oppose changes in the scope of practice for nurse practitioners, work the state budget process (click here for more on the budget), and engage in major policy initiatives such as the passage of firearm safety legislation and step therapy reform.
The first few months of 2023 have been busy, and our advocacy efforts have made a real impact. However, we still have a lot of work to do as we move into the fall session. The continued efforts by nurse practitioners to expand their scope of practice and the upcoming attacks on tort reform are significant concerns. We also have opportunities to make progress on Auto No-Fault, physician-led team-based care, step therapy reform, and many other areas.
Efforts on Scope: MSMS has made combating the continued attempts to expand scope of practice a top priority as we advocate before the Michigan Legislature. The AMA continues to be a lead partner in this important fight to defend high quality patient care and ensure physician practices have the support they need. A HUGE thank you goes to the AMA’s Scope of Practice Partnership (SOPP) program which, over the last 3 years, has provided $150,000 to MSMS to help us focus and sharpen our advocacy work. In addition to the AMA, the MiACCT (Michigan Advancing Collaborative Care Teams) coalition has been instrumental in our fight; please take a moment to review the MiACCT website and learn about the work this important coalition is doing.
Lastly, but most importantly, please remember that we need each of you and your patient stories. We need patients and physicians to come together and tell the Legislature that Michigan needs physician-led care teams. Below are a series of short updates on scope related bills which have either seen movement or are introduced/near introduction, and we are concerned there could be movement.
Nurse Practitioners: MSMS is continuing to monitor conversations surrounding nurse practitioner (NP) scope expansion legislation. Senate Bill 279 (Irwin), which allows for full independent practice for nurse practitioners without additional training or education requirements, was introduced in April and is currently sitting in the Senate Health Policy Committee. MSMS has met with key committee members and expressed our firm opposition.
As is always the case with scope legislation, our opposition is arguing that allowing nurses to practice without physician involvement will improve access to care and will encourage nurses to come work in Michigan. Unfortunately, advocates fail to point out the fact that states that have passed legislation like Senate Bill 279 have not seen an improvement in access to care. Further, data shows that under NP-led care, unnecessary testing goes up, costs go up, and patient satisfaction goes down. The facts are clear, all members of a health care team need to work together to provide high-quality patient care. Physician-led, team-based care is what we need in Michigan, not a two-tiered health care system that puts patients at risk.
Physician-Led Team-based Care: While MSMS and our physician advocates have been working hard to educate the legislature about the concerns with expanding scope of practice for NPs, we have also been looking for alternative ideas that can improve access to care and do it in a safe way for patients. We are excited about the introduction of House Bill 4472 (Farhat) which requires physician-led team-based care for NPs and PAs. PAs have already been operating under a physician collaborative agreement model, and House Bill 4472 adds NPs to that equation. The legislation allows PAs and NPs to assume specific responsibilities within the scope of their usual professional activities and stipulates that they maintain appropriate collaboration and consultation, as provided under a written practice agreement, with a patient care team physician.
We are incredibly grateful to Representative Farhat for seeing the value physician-led care brings to all Michigan residents. The people in Dearborn, Michigan truly have a great Representative.
Medical Professionals Title Transparency: Legislation is currently being drafted, at the request of MSMS, which mirrors Indiana’s law on title transparency. Our goal is to see this legislation introduced this fall and to begin the process of advancing this important issue through the Legislature.
Death Certificates: Last term, legislation was introduced in the Michigan House which allowed nurse practitioners and physician assistants to sign death certificates without physician involvement. The bill also required the implementation of an electronic signature process for death certificates.
MSMS worked with the involved stakeholders and secured changes that required a collaborative agreement with a physician for nurse practitioners or physician assistants to be the signature on such documents. Further changes were then made to the bill that fully removed the ability for nurse practitioners or physician assistants to sign, even under a collaborative agreement. The legislation passed the House last term, but stalled out in the Senate due to timing issues as the legislative term came to a close. A new bill has yet to be introduced in 2023, but the debate behind the scenes has been on-going, we will continue to closely monitor the conversation going into the fall.
Psychologists: We continue to hear discussions around allowing psychologists to prescribe controlled substances. Interested members of the legislature are focused on this issue because of concerns around access to care. There has been some willingness from interested parties to include language requiring collaborative agreements with a physician for prescribing authority to be granted. Physician-led care is imperative for patient safety, and we will continue to work toward this goal if legislation in this space is introduced.
Pharmacists: MSMS has been closely tracking Senate Bill 219 (Santana), which codifies the federal PREP Act by removing the requirement for pharmacists to work under a collaborative agreement to order and administer immunizing agents and diagnostic laboratory tests. The bill also permits pharmacists to administer diagnostic laboratory tests classified by the Food and Drug Administration (FDA) as waived. Specifically, the bill:
- Authorizes a pharmacist to order and administer a qualified immunizing agent to an individual without being under the direction of a physician.
- Authorizes a pharmacist to order and administer qualified laboratory tests.
- Includes in the scope of pharmacy practice a pharmacist’s ordering and administering qualified immunizing agents and qualified laboratory tests under the bill.
- Requires a pharmacist to successfully complete an approved training program before ordering or administering an immunizing agent or qualified laboratory test.
- Authorizes the Board of Pharmacy to promulgate rules to implement the bill.
MSMS worked with other stakeholders to substantially limit the diagnostic laboratory tests a pharmacist may administer under the bill to COVID-19, influenza, and respiratory infections. Changes were also adopted that ensured specimens for laboratory testing can only be collected by nasal swab, throat swab, or a finger prick.
Previous versions of the bill broadly expanded the scope of practice for pharmacists, and while MSMS secured substantial changes, we remained opposed to the legislation throughout the process. However, Senate Bill 219 did pass the House and Senate and was signed into law by Governor Whitmer in July.
Telehealth Parity: To ensure continuity of care and minimize the spread of COVID-19, during the pandemic, physician practices quickly adopted a telehealth patient care model. Insurance companies 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, without legislative intervention, insurance companies can revert to pre-pandemic rates at any time.
Telehealth is a vital tool for Michigan patients and physicians; in that vein, MSMS is supporting the passage of House Bill 4131 (Liberati) which imposes payment and coverage parity on telehealth services in Michigan. Specifically, House Bill 4131:
- Requires payment parity for telemedicine services as compared to the same service provided in-person.
- Prohibits annual or lifetime limits on coverage for telemedicine.
- Prohibits prior authorization requirements on telemedicine that exceed requirements for the same in-person service.
- Prohibits insurers from placing certain restrictions/requirements on telemedicine services and providers.
- Allows insurers to require telemedicine services comply with the same coding, documentation, and other requirements necessary for payment as in-person service.
- Requires that telemedicine services conform to the standards of care applicable to the provider’s profession and specialty.
We have had positive conversations with key House committee leadership on moving HB 4131, but we have yet to receive a hearing. Our hope is to see positive progress in the coming months.
Step Therapy: MSMS firmly believes that the most appropriate course of treatment for a given medical condition depends on the patient’s unique clinical situation and the care plan developed by the physician in close consultation with that patient. Unfortunately, insurance companies continue to dictate what drugs physicians can prescribe. We remain committed to passing reforms that ensure that medical decisions are made between patients and physicians. We are currently working with several legislators to draft and introduce a bill that will bring much needed reform to our step therapy process, including:
- Requiring step therapy protocols to be based on well-developed scientific standards and administered in a flexible manner that considers the individual needs of patients.
- Requiring health insurers to base their 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.
- Ensuring patients are exempt from step therapy protocols when those protocols are inappropriate or otherwise not in the best interest of the patients.
- Ensuring patients have access to a fair, transparent, and independent process for requesting an exception to a step therapy protocol when the patient’s physician deems it appropriate.
- Preserving the health care provider’s right to make treatment decisions in the best interest of the patient.
MSMS, along with the Health Can’t Wait Coalition, is hoping to see legislation introduced in the fall of 2023. We will keep you updated as more information becomes available.
Reproductive Health Care: MSMS engaged in discussions related to repealing Michigan’s 1931 abortion law in the early part of 2023. Pursuant to the direction of our Board of Directors, we focused our advocacy on ensuring the physician-patient relationship was not criminalized.
After the passage of Proposal 3 during the 2022 election cycle, the Legislature acted on the 1931 abortion law and repealed that statute in the early spring of 2023.
There are currently further conversations regarding access to reproductive health care that MSMS is closely monitoring. Items such as further updating our statute to reflect the passage of Proposal 3, elimination of the 24-hour abortion waiting period, permitting Medicaid to cover abortion services, allowing over the counter birth control, and removing parental consent requirements for minors are areas where the Legislature may look to make additional amendments to Michigan law. As these conversations happen in Lansing, we will continue to work to ensure that physicians and patients can make medical decisions uninhibited by fear of criminal prosecution.
Oral Chemo Parity: Oral chemotherapy pills have revolutionized how we administer life saving medications, offering convenience, flexibility, and an improved quality of life for countless individuals battling cancer, so they can continue to make memories with their loved ones. Yet, despite the proven effectiveness and numerous benefits of this life saving treatment, disparities persist in the coverage and affordability of oral chemotherapy compared to intravenous treatments.
We are pleased to report that the Michigan House of Representatives has passed House Bill 4071 (Steckloff) which requires health insurance companies to treat their coverage of intravenous and oral chemo drugs the same. The passage of this legislation is a significant win for patients and physicians. House Bill 4071 is now in the Michigan Senate Health Policy Committee for additional consideration. M. Salim U. Siddiqui, MD, PhD, MSMS President, provided testimony in support of the bill to the House Health Policy Committee and we hope to be able to work similarly with Senate Health Policy in the coming months.
Lead Testing for Children: Shortly before the Legislature adjourned for the summer, the House Health Policy committee passed Senate Bill 31 (Cherry), which requires children to be tested for lead poisoning when they visit a physician. The bill, which previously passed the Michigan Senate, amends the Public Health Code, and includes the following provisions:
- Beginning January 1, 2024, a physician treating a patient who is a minor (under 18 years of age) would have to test the minor for lead poisoning (or order the test) at intervals specified by DHHS rule.
- A physician who performs a lead poisoning test as described above would have to make an entry of the testing on the minor’s certificate of immunization. Beginning January 1, 2024, a certificate of immunization would have to include a space to indicate whether the minor has been tested for lead poisoning.
The legislation also requires DHHS to promulgate rules to implement the new statute, the rules are required to include at least all of the following:
- A requirement that a minor residing in Michigan be tested at 12 months (one year) of age and 24 months (two years) of age, and a requirement that a minor residing in Michigan be tested between 24 months (two years) of age and 72 months (six years) of age if they have no previous record of the test required by the bill.
- The identification of geographic areas in Michigan that pose a high risk for childhood lead poisoning and a requirement that a minor who is 48 months (four years) of age be tested if they reside in one of those geographic areas.
While MSMS continues to support measures to increase lead screenings for minors, we have concerns with how provisions of the bill would be applied. We worked with the Michigan Association of Family Physicians (MAFP) and the Michigan Chapter of the American Academy of Pediatrics (MIAPP) to secure several changes to the legislation, however, all three organizations currently remain neutral. We will continue to monitor Senate Bill 31 as it receives further consideration before the Michigan House of Representatives.
Affordable Care Act Codification: On March 30th, 2023, a judge in the U.S. District Court struck down a critical provision of the Affordable Care Act (ACA) that requires most private health plans to cover a range of preventative services without any cost sharing for their enrollees. Should this ruling hold, millions of individuals could find themselves burdened with increased costs for preventative care and even worse, some may lose access to essential services altogether.
The House and Senate subsequently introduced an eight-bill package, Senate Bills 356-358, and House Bills 4619-4623, which accomplish the following:
- Prohibits insurers from engaging in discriminatory practices based on gender and sexual orientation (HB4619)
- Prohibits insurers from imposing annual or lifetime limits on benefits (HB4620)
- Prohibits denial of coverage for pre-existing conditions (HB4621)
- Requires coverage of dependents up to the age of 26 (HB4622)
- Requires coverage of preventative services (HB4623)
- Requires insurers to provide a form explaining the terms and conditions of the policy to applicants and enrollees at the time of application, issuance, and renewal (SB356)
- Prohibits insurers from rescinding coverage unless the insured performs an act of fraud or makes an intentional misrepresentation of material fact. The insurer would have to give written notice to the insured at least 30 days before the rescission (SB357)
- Requires insurers to provide at least one level (60%, 70%, 80%, or 90% of full actuarial value) of coverage. The insurer is also required to offer coverage at that level as child-only coverage (SB358)
In early June, the Senate Health Policy Committee heard testimony on Senate Bills 356-358. MSMS President, M. Salim U. Siddiqui, MD, PhD, submitted testimony in support of Senate Bills 356 and 357. Shortly after this hearing, MSMS Board Member and Legislative and Regulatory Committee Chair, Michael Redinger, MD, testified in support of House Bills 4619-4623 in the House Insurance and Financial Services Committee. Both packages of bills have passed their respective chambers with bi-partisan support and will likely be acted on come the fall legislative session which begins in September.
Healthy Michigan Plan Reform: As a result of the Affordable Care Act’s (ACA) Medicaid expansion allowance which passed in 2010, the Michigan Legislature created the Healthy Michigan Plan (HMP) to expand Medicaid coverage for adults in Michigan with income up to 138 percent of the Federal Poverty Level. Today, the HMP provides health care coverage to over one million Michigan citizens.
While the HMP is exceeding its goals of reducing the state’s tax burden and uninsured/uncompensated care rate, outdated mandates on enrollee cost-sharing and health risk assessments had created barriers to accessing coverage and care for many in our most vulnerable populations. Further, state cost-saving requirements allowed future administrations to terminate the HMP if state savings were reduced, placing over one million Michigan citizens at risk of losing health care coverage.
House Bill 4495 (Snyder) and House Bill 4496 (Filler), which were recently signed into law, addressed these issues by eliminating cost-sharing requirements for HMP enrollees, repealing the HMP termination provisions, and allowing health plans more flexibility in creating benefit packages that improve health outcomes for enrollees. The bills passed the House and Senate with bi-partisan support and were signed into law by Governor Whitmer in July.
Firearm Safety: This Spring, Governor Gretchen Whitmer signed legislation requiring the safe storage of firearms, universal background checks on all firearm purchases, and implemented Extreme Risk Protection orders (also known as Red Flag Laws). MSMS worked with a coalition of like-minded organizations to advance these policies through the Legislature and to the Governor’s desk.
Safe Storage law requires the owner of a firearm to keep it in a lockbox or container or to have it unloaded with a locking device. The law contains felony provisions for not having a safely stored weapon that a child gains access to and injures or kills another person, while also spelling out various exemptions. Lastly, firearm safety devices are exempt from the Michigan sales and use tax through 2024.
The Background Check law is simple, it requires background checks on all Michigan firearm purchases.
The new requirements allowing Extreme Risk Protection Orders (ERPO) permit a spouse/former spouse, family member, significant other, law enforcement officer, or mental health professional to file a summons and complaint against a defendant who poses a significant risk of personal injury to themselves or others by possessing a firearm. The law prohibits people under an ERPO from purchasing a firearm, provides service of process for ERPO actions, and waives related court fees. A violation of the ERPO order is a felony, and it is a misdemeanor to make a false statement when seeking an order under the act.
A special thanks goes to Brian Stork, MD, who led the charge for MSMS on this important issue. Doctor Stork visited Lansing multiple times over several weeks in the spring to speak to legislators and testify before multiple legislative committees. MSMS made an impact on advancing firearm safety because of the dedication of Doctor Stork and so many other physicians who chose to make their voices heard.