2018 Legislative Priorities

 2018 Legislative Priorities

  Final General Assembly Report

 This was a unique cycle in Virginia politics. A Democratic wave in the November 2017 elections reduced the Republican majority in the House of Delegates from 66 to 51 seats after a rollercoaster ride of close district elections, ballot recounts, and a tiebreaker that kept Republican control of the House by two seats. Coupled with the election of a new Governor and Lieutenant Governor (and the reelection of the incumbent Attorney General), we were in a holding pattern as we awaited election results that would determine which party controlled the House, and with it the Speakership, committee chairmanships, committee assignments, and the overall dynamic with the executive branch. As a result, the lead-up to and start of session on January 10 was anything but typical.

Del. Kirk Cox (R-Colonial Heights) was unanimously elected as Speaker and rules were adopted keeping proportional representation on the committees. All committee meetings are now being live streamed, and subcommittee votes on legislation are recorded.

March 10, 2018 was Sine Die, the last day of this year’s General Assembly regular session, but legislators finished without producing a final budget. The two chambers were at an impasse over the expansion of Medicaid and how to spend- or cut- $600M. The House, in collaboration with Governor Northam, included Medicaid expansion in their version of the budget while the Senate did not.

Governor Northam called a special session to focus solely on the budget of the General Assembly, which convened on April 11th. Procedurally, the Governor sent down a budget bill that is virtually identical to Governor McAuliffe’s introduced budget. The House of Delegates conformed that budget to be almost identical to their previous version, again including Medicaid expansion. Unusually, after the House passed their version, the Senate took up the bill, referred it to committee and then did not meet again. The Senate Republican Caucus remained adamantly opposed to expanding Medicaid, save for Senator Emmett Hanger who supported expansion and has for years.

Senator Tommy Norment, Senate Majority Leader and co-Chair of the Finance Committee with Senator Hanger, called for the Senate to convene on May 22nd.  Prior to the convening of the Senate on the 22nd, Senator Emmett Hanger (co-Chair of the Finance Committee), Delegate Chris Jones (Chair of the Appropriations Committee) and Governor Northam held a series of meetings to work out a unified budget.  This resulted in roughly 300 compromise amendments to the budget, while still retaining Medicaid expansion.

When the Senate met on May 22nd there was a great deal of hesitancy about voting on the budget with so little review of the amendments, which was really a cover for the continued opposition to Medicaid expansion.  Senator Hanger relented to his caucus and extended the courtesy of a week to review the compromise amendments, with the Senate Finance committee convening on Tuesday, May 29th at Noon to consider the budget and the new package of amendments.  It is widely believed that if the Senate Finance Committee failed to pass out a budget or failed to include expansion, that the package of amendments will either be adopted on the floor of the Senate using the discharge method, or, allow a bill through that the Governor would then amend with the compromise amendments, sending it back to both houses to approve on the floor, where the votes are present to pass it on both sides.

The Senate Finance committee voted out a bill that did NOT include expansion, but it was inevitable that it would be added back in on the Senate floor where there were enough Republicans willing to vote to support expansion- Hanger, Wagner, Chafin and Vogel- along with the 19 Democrats.

After a long day of debate, the Senate passed the budget with Medicaid expansion on Wednesday, May 30th and the House accepted the amendments later that evening, sending the budget to the Governor for his review and signature, finally ending the extended special session.

Healthcare continued to be a focus for the legislature, with the discussion focusing mainly on whether Medicaid would be expanded or not. VA AAP, along with our family physician and emergency physician colleagues, sent a joint letter to the budget conferees and the Administration voicing our support for expansion and requesting them to consider additional reforms as part of the implementation process.

Since 2016 the physician community has been actively involved in efforts to engage the General Assembly in dialogue, which would result in the passage of a thoughtful, statewide phase-out of the COPN regulatory process. Following the 2017 General Assembly Session and much discussion with senior members of the House of Delegates and Senate, the physician specialties involved decided to try a different approach and introduce individual project exemption legislation.

Twenty-five individual COPN exemption bills were introduced during the 2018 General Assembly Session Most of the bills died, but one bill calling for statewide repeal of COPN was carried over to the 2019 Session. House Health, Welfare and Institutions Committee Chairman Bobby Orrock announced that he will convene a workgroup starting this April to study COPN during the off-session.

Nurse Practitioner ‘Transition to Practice’ (HB 793- Robinson)

Virginia has passed the most stringent nurse practitioner “transition to practice” model in the country, requiring not only five years of post-graduate training for NPs, but also that the training be with a physician working with the same patient population and in the practice area the NP is trained. Governor Northam signed House Bill 793 into law without any amendments. The effort to create a transition to practice model for NP practice is thanks to the advocacy efforts of the physician community, VA AAP, MSV, and other specialty groups. The regulatory process will begin immediately at the Department of Health Professions and we will continue to advocate during that process.

The bill specifically includes the following guardrails: leaves the current law in place for collaborative practice but creates a separate transition to practice pathway with: education from an accredited university; five years of practice with a physician, not another nurse practitioner, working with the same patient population and in the practice area the NP is certified and licensed in; signed attestation from the physician they practiced with to the Joint Boards signing off on their ability to practice independently; limiting their practice to the scope of their clinical and professional training and limits of knowledge and experience; continuing to consult and collaborate with other healthcare providers; and having a clear plan for referrals of complex cases and emergencies.

Step Therapy and Prior Authorization

Physician groups, patient advocates, and pharmaceutical companies continue to seek policy changes that will reduce burdens of insurance company practices that deny or delay prescriptions for patients. Insurance lobbyists argue that these are necessary to control costs based on clinical practice guidelines. Senator Bill DeSteph (SB581) and Delegate Glen Davis (HB386) introduced bills that have received a lot of attention but have not advanced during the last few sessions. MSV has signaled they will make this a priority item in 2019.

Credentialing Reimbursement

Delegate Chris Head introduced HB 139 which will require insurance companies to reimburse physicians during a credentialing application period. Reimbursement will occur retroactively upon completion of credentialing. MSV estimates that, on average, this has the potential to avoid lost revenue of $100,000 – $150,000 per physician over a 90-day period. The bill passed both houses and was signed into law by the Governor.

Increasing Recess

The VA Chapter, AAP supported the two bills HB1419 (Delaney)/SB273 (Petersen) that increased the amount of recess offered in school. Both bills passed their respective houses and have crossed over and reported out of the opposite chambers committees. However, they were not in the exact same form and had to go to a conference committee so the changes were worked out before it was signed by the Governor into law.

Rear Facing Child Car Seats

Delegate Filler-Corn’s HB 708 required child restraint devices to not be forward-facing until at least (i) the child reaches two years of age or (ii) the child reaches the minimum weight limit for a forward-facing child restraint device as prescribed by the manufacturer of the device. The bill has a delayed effective date of July 1, 2019. It has been signed by the Governor.

Doctorate of Medical Science

We opposed SB505 (Carrico) that created a new license for physician assistants who completed a newly created doctorate program at a university in Tennessee. It met with a lot of opposition from the physicians and physician assistant because this brand-new degree is untested and not yet accredited. The first class just started in the Fall of 2016 and we believe it is far too early for Virginia to grant a new license for such a nascent profession. The bill was continued until 2019, killing it for the year.

Safe Storage of Firearms                                                                                                 

We supported Delegate Filler-Corn’s HB172 that established a retail sales tax exemption for the purchase of a gun safe with a selling price of $1,000 or less. Because unintentional injuries continue to be the leading cause of death in children older than 1 year, minimizing the risk of injury in the child’s everyday environment, including locking up firearms, play a key role in injury prevention. Unfortunately, the bill failed to advance despite it being supported by pro and anti-gun groups and the pediatricians.

Other Bills VA AAP Followed in 2018:

SUPPORTED HB1080 (Yancey) Supporting Mothers Who Breastfeed: DEAD for the YEAR

This bill passed the House Commerce and Labor committee for the first time this year, but was tabled in House Appropriations Committee and is dead for the year. This bill would require employers to provide reasonable unpaid break time each day to express breast milk for one year after the child’s birth and make reasonable efforts to provide a room or other location in close proximity to the work area, other than a toilet stall, where such an employee can express breast milk in privacy.

OPPOSED SB675(Deeds) Food Safety; No inspections for yogurt: DEAD for the YEAR

This bill would have exempted private homes that prepare yogurt from inspections by the Commissioner of Agriculture and Consumer Services. We worked with the agribusiness community on this bill again, as we have in years past on raw milk.

SUPPORTED HB791 (Pogge): This bill was TABLED in House Appropriations because of the inherent cost for localities to implement this bill. This bill would require at least one school nurse in every elementary, middle and high school in a school division.

As usual, healthcare continued to be a focus for the legislature. They were hesitant to pass any   major reform bills due to the uncertainty at the federal level with the Affordable Care Act and have created a legislative work group to monitor the changes in the ACA and determine their impact on Virginia.

Mental health reform remained a consistent topic of discussion, but without a lot of true reform occurring. The General Assembly allocated a total of $500K for two different studies of the mental health system- half to the Secretary of HHR and then the other half to the Deeds Commission, which has been extended for another two years.

The opioid epidemic was a huge focus of the 2017 legislature. As part of the opioid conversation, VA AAP supported bills that focused on the most vulnerable victims of the opioid epidemic- babies suffering from Neonatal Abstinence Syndrome (NAS). Below are the opioid related bills and budget items:

Every year we face bills that seek to change the scope of practice for mid-level providers. We saw a bill that was the first in the nation- a bill to create a doctorate of medical science put forth by Lincoln Memorial University in Tennessee.

Final Budget Items

Budget Item 30#2c:

This amendment adds language directing the Joint Commission on Health Care to examine and identify strategies to increase public awareness of the risks and concerns related to the use of psychiatric medications used to treat Attention Deficit Hyperactivity Disorder (ADHD) and other disorders.

Budget Item 291#1c: This amendment requires the state teaching hospitals to work with the Department of Health and Division of Vital Records to fully implement use of the Electronic Death Registration System (EDRS) for all deaths occurring within any Virginia state teaching hospital’s facilities. Full implementation shall occur and be reported, by the Division of Vital Records, to the Chairmen of the House Appropriations and Senate Finance Committees by April 15, 2018, in alignment with Vital Records plans to promulgate and market the EDRS. 

Budget Item 30#1c: This amendment directs the Joint Commission on Health Care to study options for increasing the use of telemental health services in the Commonwealth.

 

2016 Legislative Priorities

Preservation of Team-Based Patient Care

Oppose NP Independent Practice bills

  • In 2012, the physician community and the nurse practitioners agreed upon a new model for care that was a team based and led by a physician. This model is collaborative and we believe provides the best patient care while allowing everyone to practice to the fullest extent of their education and training.
  • We would support compromise language that has been proposed raising the ratio of nurse practitioners and physicians from 1 to 6 to 1 to 9 for free clinics and Federally Qualified Health Centers in underserved areas.
  • We also support compromise language that allows nurse practitioners whose collaborating physician dies, moves away or loses their license to practice for a limited time with the local health director serving as their collaborating physician until a new private physician can be found.

Immunizations Support

HB 1342 (Filler-Corn/Stolle)

  • Support legislation to only allow children to be exempted from the school entrance required vaccines if there are medical contraindications.
  • Routine childhood immunization is one of our crowning achievements in public health over the past century. A 2013 New England Journal of Medicine study estimated that childhood vaccination programs have prevented 103.1 million cases of diphtheria, hepatitis A, measles, mumps, pertussis, polio and rubella since 1924. A 2005 Archives of Pediatric and Adolescent Medicine study estimated that for every dollar spent in the US, vaccination programs saved more than $5 in direct costs and approximately $11 in additional costs to society.
  • 71.6% of children between the ages of 19 and 35 months were immunized according to ACIP/AAP/AAFP/ACOG recommendations in 2014.
  • However, challenges remain. 28,660 cases of whooping cough (pertussis) were reported in the US in 2014. A multistate outbreak of measles linked to an amusement park in California led to 188 cases in 24 states from Jan 1 to Aug 21, 2015. Most measles patients were unvaccinated against the disease.

Child Safety: Ban Tanning for Children under 18 Support

HB 356 (Garrett)

  • Support legislation to prohibit minors younger than 18 from using tanning facilities.
  • Sunlamps and tanning beds are the main sources of deliberate artificial UVR exposures. The intensity of UVA radiation produced by large, powerful tanning units may be 10 to 15 times higher than that of the midday sun.
  • •rtificial tanning is a common practice among teenagers. Use of a tanning facility at least once in their lives was reported by 24% of non-Hispanic white teenagers 13 to 19 years of age in a US sample.

In another national survey, 10% of youths 11 to 18 years of age reported using indoor tanning sunlamps in the previous year.

Protect Children from Secondhand Smoke in Cars Support

HB 1348 (Pillion)

  • Support legislation to prohibit smoking in cars when children under the age of eight are present.
  • Exposure to secondhand smoke in cars is especially dangerous for children
  • Secondhand smoke in motor vehicles can be up to 27 times more concentrated than in a smoker’s home.

Budget Items

Virginia Pediatric Mental Health Collaborative Support

House: Item 306 #33h (Garrett) Senate: Item 310 #4s (Barker) FY17: $50,000

The VA AAP recognizes that the unmet mental health needs of young children, especially those who have not yet entered school, are great. We are committed to addressing the mental health needs of diverse children and their families through culturally competent and family focused initiatives. Our goal as pediatricians is to improve the integration of mental health in pediatric primary care for children in the Commonwealth, paying particular attention to the needs of infants, toddlers and preschoolers.

New Language:

“2. The Virginia Center for Healthcare Innovation shall establish the Virginia Pediatric Mental Health Collaborative with the Virginia Chapter, American Academy of Pediatrics, Voices for Virginia’s Children, the Psychiatric Society of Virginia, VCU and UVA’s Department of Psychiatry, the Virginia Academy of Family Physicians, the Department of Medical Assistance Services (DMAS), the Department of Behavioral Health and Developmental Services (DBHDS), the Virginia Association of Community Services Boards and other relevant stakeholders. The goal of the Collaborative is to improve the integration of mental health in primary pediatric care for children in the Commonwealth.

By October 1, 2016, the Collaborative shall survey existing collaborative efforts between pediatricians, family physicians and the children’s mental health system and create a plan to implement pilot programs creating child mental health access projects through which a mental health consultation team is available by telephone to respond promptly to pediatricians who need assistance with managing their patients’ mental health needs. The consultation teams provide clinical consultation to enhance pediatricians’ abilities to evaluate, treat, co-manage and refer children with mental health problems.

During this planning grant, the Center shall be assisted when necessary by DMAS, the Virginia Center for Healthcare Innovation, and DBHDS, with technical assistance provided by Children’s National Health System, a co-founder of the DC Collaborative for Mental Health in Pediatric Primary Care.”

Medicaid Substance Use Disorder Benefit (SUD) SUPPORT

Item 306, MMMM and NNNN in Introduced Budget FY17 $2M FY18 $8M

Current community and inpatient options for substance abuse treatment programs are significantly limited, particularly for Medicaid patients. With the current opioid and prescription drug abuse crisis, we need to ensure that patients, especially pregnant woman, who seek treatment are able to receive it.

  • Neglect due to SUD was the #2 reason that children entered foster care in Virginia in 2013 but 91% of caregivers with children in Virginia’s foster care system and substance abuse treatment needs reported they had not received treatment in the past 12 months.
  • 1,085 Medicaid babies were born with Neonatal Abstinence Syndrome in Virginia in 2014, resulting in expensive NICU stays. Many of their moms couldn’t obtain opiate addiction treatment during pregnancy.

Therefore, we support the language in the introduced budget that makes more inpatient and residential treatment available, as well as raising rates for the provision of such services.