Governor’s Action at the End of the 2013-2014 Legislative Term

BILLS SIGNED:

• 2012:S374 / 2012:A4526 (Beach, Allen, Sarlo, Lampitt, Casagrande) – Exempts from sales tax cosmetic makeup services provided in conjunction with reconstructive breast surgery; designated as “Jen’s Law”
• SCS for 2012:S782wGR (Weinberg, Cunningham) – “New Jersey Hospital Disclosure and Public Resource Protection Act”
• 2012:S792 / 2012:A2022 (Weinberg, Singleton, Benson, Johnson, Lampitt, Quijano, Vainieri Huttle) – Requires insurers to cover breast evaluations and other additional medically necessary testing under certain circumstances and requires certain mammogram reports to contain information on breast density
• 2012:S2367 / 2012:A4415 (Codey, Beach, Eustace, Jasey, Caride, Wimberly) – “Sudden Cardiac Arrest Prevention Act”; provides student-athletes, parents, and coaches with information on sudden cardiac arrest and establishes protocol concerning removal-from-play for athletes exhibiting symptoms of sudden cardiac arrest
• 2012:S2448 / 2012:A3766 (Turner, T. Kean, Watson Coleman, Munoz, DeCroce, Riley, Benson) – “Higher Education Epinephrine Emergency Treatment Act”
• 2012:S2843 / 2012:A4280 (Weinberg, Addiego, Lampitt, DeCroce, Mosquera, Casagrande) – “Autumn Joy Stillbirth Research and Dignity Act”; requires DOH to establish protocols for stillbirths, establishes stillbirth research database
• 2012:S2995 / 2012:A4486 (Weinberg, Madden, Lampitt, Johnson, Wimberly, Sumter) – Prohibits discrimination based on pregnancy, childbirth or related medical conditions
• 2012:SJR74 / 2012:AJR100 (Weinberg, Singleton, Chivukula) – Designates June of each year as “Congenital Adrenal Hyperplasia Awareness Month”
• 2012:A3039wGR / 2012:S2033 (Conaway, Lampitt, Benson, Jimenez, Whelan) – Establishes NJ Task Force on Lupus Education and Awareness in DOH
• 2012:A3251 / 2012:S2567 (Ramos, O’Scanlon, Jimenez, Vitale, Singer) – Permits pharmacists to administer influenza vaccines to children seven years of age or older
• 2012:A3558 / 2012:S2606 (Benson, Chivukula, Lampitt, Eustace, Codey, Madden) – Provides for licensure of pediatric respite care facilities
• 2012:A3978 / 2012:S2832 (Lampitt, Casagrande, Vainieri Huttle, Madden, Oroho) – Requires hospitals and birthing facilities to provide new mothers with information about pertussis vaccines for adults

BILLS THAT EXPIRED WITHOUT GUBERNATORIAL ACTION (POCKET VETOED):

• 2012:S162 / ACS for 2012:A1269 / 2012:A4507 (Singer, Vitale, Greenwald, Coughlin, Prieto, Riley, Lampitt, Casagrande, Wimberly, Conaway) – Provides loan redemption for certain physicians who work in State four years
• 2012:S1598 / 2012:A1097 (Weinberg, Vitale, Quijano, Wimberly, Munoz, Jasey) – Permits attending advanced practice nurse to determine cause of death and execute death certification of patient if nurse is patient’s primary caregiver
• 2012:S2241 / 2012:A3409 (Weinberg, Vitale, Singer, Schaer, Johnson, Riley, Eustace, Vainieri Huttle) – Prohibits Medicaid managed care organizations from reducing certain provider reimbursement rates without approval from DHS
• 2012:S2318 / 2012:A3390 (Vitale, Addiego, O’Donnell, Coughlin) – Requires newborn infant screening for tongue tie
• 2012:A765 / 2012:S1220 (Barnes, Quijano, Gusciora, Eustace, Vitale, Scutari) – Requires registered qualifying patient’s authorized use of medical marijuana to be considered equivalent to use of any other prescribed medication.
• 2012:A1214 / 2012:S1623 (Stender, Conaway, Webber, Benson, Quijano, Whelan, Weinberg) – Establishes pilot program to utilize value-based benefit design in SHBP to increase health benefits coverage for certain employees concerning chronic health conditions
• 2012:A2172 / 2012:S1464 (Conaway, Singleton, Giblin, Vitale) – Requires certain health care facilities to offer, and health care workers to receive, annual influenza vaccination

Lame Duck 2013 Gubernatorial Action – Two Successes for Physicians

Lame Duck 2013 Legislative Action
(the Governor has 10 days to sign or pocket veto all bills signed at the end of the two year legislative session)

APN Scope of Practice

Despite our protest, both houses have passed a bill that would permit Advanced Practice Nurses to certify cause of death.  MSNJ opposes this bill because cause of death is in fact a medical diagnosis and should be provided only by a physician. Read MSNJ’s opposition letter. We are hoping for a pocket veto by the Governor, as he did two years ago when the Legislature rushed the bill through in an identical manner.

Pharmacy Vaccines

A3251, the bill allowing pharmacies to administer vaccines has passed both houses and awaits action by the Governor. The bill allows pharmacies to administer to patients 18 and older a vaccine (1) pursuant to a prescription, (2) in immunization programs authorized by a prescriber’s standing order for the vaccine or (3) in immunization programs and programs sponsored by governmental agencies that are not patient specific .  Under the bill, a pharmacist may administer an influenza vaccine to a patient who is seven years of age or older.  For a patient who is under 18 years of age, a pharmacist shall not administer a vaccine except with the permission of the patient’s parent or legal guardian.  For a patient who is under 12 years of age, a pharmacist shall not administer a vaccine unless pursuant to a prescription by an authorized prescriber.  A patient 12 years of age or older does not need a prescription for an influenza vaccine. MSNJ, NJAFP and NJAAP opposed this bill in its original form, but softened when the vaccines for children were limited to flu. This bill still represents a scope of practice expansion of concern to MSNJ.

Physician Loan Redemption

The Legislature passed S162, which establishes a Physician Loan Redemption Program. The bill awaits action by the Governor. MSNJ, along with NJ AFP and COTH worked expediently to improve the bill that was passed by the Senate in a skeletal, flawed form.  With our input, the bill now provides for redemption of eligible qualifying loan expenses for physicians who work for no less than four years at an approved site in the clinical practice of primary care or in the clinical practice of specialized care if the specialty is projected to experience a significant shortage.

Pain Medicine Restrictions

The Senate Budget Committee approved a bill that would limit insurers from using step therapy protocols for pain medication. Though the bill had already passed the Assembly, the Senate failed to vote on it, so it died at the end of the legislative session. MSNJ supported this bill and will work with legislators on the issue in 2014.  Our larger goal is to balance drug abuse reduction with proper access to pain medicine for patients who need it.

Medicaid Provider Rates

Both houses passed S2241, which would prohibit Medicaid managed care organizations from reducing certain provider reimbursement rates without approval from DHS.  The bill stems from an attempt by Horizon last year to slash home care provider rates after the Governor began moving most Medicaid services from fee for service to managed care. The insurance companies oppose the bill and stated that the bill would create a regulatory situation that is not used by any other state and that it will ultimately increase costs to the state. They also stated that the record of managed care in New Jersey is very good and the system is fair. MSNJ supports the bill, which awaits action by the Governor.

Higher Education Epinephrine Emergency Treatment Act

Both houses passed S2448, which allows public and independent institutions of higher education in New Jersey to develop a policy for the emergency administration of epinephrine to a member of the campus community for anaphylaxis when a medical professional is not available.  Institutions of higher education that develop such policies must designate an appropriately licensed physician, physician assistant, advanced practice nurse, or registered nurse to serve as the “licensed campus medical professional,” who will oversee the institution’s epinephrine administration and train designees in the administration of epinephrine via a pre-filled auto-injector mechanism.  The Secretary of Higher Education is to establish guidelines for the development of a policy for the emergency administration of epinephrine, which will be disseminated to the president of each institution of higher education.  In addition, the bill provides immunity for a licensed campus medical professional, a trained designee, and a prescribing physician for good faith acts or omissions committed in accordance with the bill’s provisions.   MNSJ supports this bill, which awaits action by the Governor.

State Trauma Plan

Both houses passed a bill that provides for the establishment of a formal Statewide trauma care system plan, which will include all health care facilities in the State providing care to injured patients in the State, to the extent that their resources and capabilities allow.  The Department of Health sought counsel with the American College of Surgeons Trauma System Evaluation and Planning Committee regarding the State’s trauma system.  This bill incorporates the recommendations that resulted from that interaction.  The commissioner is required to appoint a State Trauma Medical Director to oversee the planning, development, ongoing maintenance, and enhancement of the formal trauma system in collaboration with a multidisciplinary advisory body called the State Trauma System Advisory Committee (STSAC).  The STSAC is required to study the State’s trauma care system, collect data, and provide a report on the development of a formal Statewide trauma system plan.  The STSAC’s recommendations will provide the basis for the commissioner’s development of regulations implementing the plan.  The STSAC’s initial report, containing the formal Statewide trauma system plan, is due within one year.  Thereafter, the STSAC will be required to systematically review strategies to maintain and improve the State trauma system, submit an annual report to the commissioner and the director on its activities, and provide recommendations it determines are necessary to improve the State trauma system.  MSNJ is neutral on this bill, which awaits action by the Governor.

Breast Density

Both houses have finally passed the final version of A2022/S792, which now awaits action by the Governor.  MSNJ worked on this bill in great detail. The bill 1) requires insurance companies to cover certain screenings, 2) requires physicians to provide information to  certain patients regarding breast density and 3) requires study of breast cancer risk factors. Radiology facilities must distribute to certain patients a notice that reads as follows: “Your mammogram may show that you have dense breast tissue as determined by the Breast Imaging Reporting and Data System established by the American College of Radiology.  Dense breast tissue is very common and is not abnormal.  However, in some cases, dense breast tissue can make it harder to find cancer on a mammogram and may also be associated with a risk factor for breast cancer. Discuss this and other risks for breast cancer that pertain to your personal medical history with your health care provider.  A report of your results was sent to your health care provider. You may also find more information about breast density at the website of the American College of Radiology, www.acr.org.” The bill states that it does not impose a standard of care obligation upon a patient’s health care provider.  The bill requires the Mandated Health Benefits Advisory Commission to prepare a report regarding the implementation and administration of the bill, including analyses of social, medical and financial impact. The bill requires the Department of Health, in conjunction with the Medical Society of New Jersey, to convene a work group to review and report on strategies to improve the dialogue between patients and health care professionals regarding risk factors for breast cancer and breast imaging options.  Though we may have improved the bill, MSNJ remains concerned about legislative interventions into the physician-patient relationship, in general, and notification mandates, specifically.

For Profit Hospital Reporting

After two years of amendments and negotiations, a bill regarding for profit hospitals is finally settled. The Governor rejected a bill in 2012 that would have required detailed financial reports by for profit hospitals, which were growing in numbers at the time.  On the last day of the two year session, the Legislature accepted the watered down rewrite of the bill by the Governor.  The bill now requires the Commissioner of Health to undertake a review of New Jersey’s hospital financial reporting requirements and shall report any findings and recommendations directly to the Governor no later than six months from the date of enactment of.  Specifically, the Commissioner shall examine the impact of, and make recommendations on, the following areas for all entities receiving Health Care Subsidy Fund payments from the State: Internal Revenue Service filings, Securities and Exchange Commission filings, and audited financial statements. The bill takes effect immediately.

Vaccines for Healthcare Workers

Both houses passed A2172, sponsored by Chairman Herb Conaway, which requires health care facilities to annually offer influenza vaccination to their health care workers and require the implementation of an annual influenza vaccination program in accordance with the current recommendations of the Advisory Committee on Immunization Practices of the federal Centers for Disease Control and Prevention and any rules and regulations adopted by the Commissioner of Health.  In lieu of receiving the vaccine at work, a health care worker would be permitted to present acceptable proof, including an attestation by the health care worker, of a current influenza vaccination from another vaccination source, or sign a written declination statement.  Each facility would be required to maintain a record of influenza vaccinations, retain each signed attestation and declination statement, and report to the Department of Health (DOH) the vaccination percentage rate of its health care workforce as part of its program or by other means as attested to by the health care worker.  Each facility would also be required to provide an educational component to its influenza vaccination program and annually evaluate the program with the goal of improving the rate of vaccination among its health care workers. The bill awaits action by the Governor, who pocket vetoed the bill last year.

Newborn Screenings

Both houses passed S2318, a bill that requires newborn infant screening for tongue tie. MSNJ was neutral on the bill.  The bill awaits action by the Governor.

Stillbirth Education

Both houses passed the  “Autumn Joy Stillbirth Research and Dignity Act,” which requires DOH to establish protocols for stillbirths and establishes a stillbirth research database. The bill awaits action by the Governor.

Pediatric Respite Care

Both houses approved A3558, which would provide for licensure of pediatric respite care facilities.  The facilities will provide end-of-life care for children up to age 21 with limited life expectancies or complex, life-limiting illnesses and support for their families, and employ interdisciplinary teams to assist in providing curative treatment when possible, palliative care, and supportive services to meet the physical, emotional, spiritual, social, and economic needs of children and their families during illness, as well as during dying and bereavement if no cure is attained. The bill awaits action by the Governor.

Drug Adherence Efforts

Both houses passed A1214, which requires the State Health Benefits Commission and the State Health Benefits Plan Design Committee to establish a three-year pilot program to provide benefits coverage to select employees with chronic health conditions using a value-based benefit design under the State Health Benefits Program (SHBP).  The value-based benefit design will target the following chronic health conditions: diabetes, high cholesterol, hypertension, and asthma. The coverage design will utilize explicit financial incentives to increase the employee’s interaction with appropriate health care providers, and encourage use of those health benefits that specifically relate to the employee’s chronic health condition.  The value-based benefit design pilot program will assign a participating employee to a pharmacist, who, in collaboration with the employee’s primary treating physician, will be responsible for coordinating medication therapy management services within the scope of the pharmacist’s license to practice pharmacy in the State of New Jersey.

The following financial incentives directly related to the diagnosis, care, mitigation, or treatment of the condition for which the employee is participating in the program will be provided:

(1) all tuition costs for any education class attended by the employee which provides medical condition self-management, recommended to the employee by the primary treating physician or assigned pharmacist;

(2) all costs for private visits with the employee’s assigned pharmacist;

(3) all costs for a medical device or supply deemed medically necessary by the primary treating physician or assigned pharmacist;

(4) all costs for laboratory testing; and

(5) waiver of all copayments for any prescription drug..

This bill is based on the well-known Ashville Project.  The bill will most likely be approved by the Senate and head to the Governor’s desk in lame duck.

Reconstructive Breast Surgery

Both houses passed S374, which grants a state sales tax exemption for services prescribed by a doctor in conjunction with reconstructive breast surgery. The procedures, currently subject to the 7 percent tax rate, are utilized to restore the appearance of the breast.  The bill addresses a current loophole where insurance providers cover the costs of the procedures but pass on the cost of the sales tax to the patient.  The bill awaits action by the Governor.

Medical Marijuana

Both houses passed A765, which requires that a registered qualifying patient’s authorized use of medical marijuana be considered equivalent to using any other prescribed medication and not the use of an illicit substance that would otherwise disqualify a qualifying patient from needed medical care, including organ transplantation.  The bill awaits action by the Governor.

Lame Duck 2013 Veto Action

Gender Changes on Birth Certificates

The Senate and Assembly have both passed A4097/S2876, which allows more people to change their birth certificates.  To obtain the amended certificate, a person would be required to submit:  1) a form provided by the State registrar of vital statistics and completed by the person’s licensed health care provider which indicates that the person has undergone clinically appropriate treatment for the purpose of gender transition, based on contemporary medical standards, or that the person has an intersex condition; and 2) a certified copy of a court order indicating the person’s name change, if the person has changed his or her name.  Under current law, a person is required to undergo sex reassignment surgery to receive an amended birth certificate.

Declarations of Death

The Governor signed a bill that removes the statutory authority of the Department of Health (DOH) and the State Board of Medical Examiners (BME) over medical standards governing declarations of death upon the basis of neurological criteria.  The bill requires that a declaration of death upon the basis of neurological criteria be made by a licensed physician professionally qualified by specialty or expertise, based upon the exercise of the physician’s best medical judgment and in accordance with currently accepted medical standards.  Joint DOH/BME regulations would no longer be needed to set forth currently accepted medical standards (including criteria, tests, and procedures) to govern declarations of death upon the basis of neurological criteria.  If they are used, the regulations concerning the declaration of death upon the basis of neurological criteria may not require the use of any specific test or procedure in the declaration of death upon the basis of such criteria. MSNJ supports this bill.

Self-Referral Laws

The Governor signed a bill which allows practitioner with financial interest in health care service providing lithotripsy to refer patients to that health care service if certain conditions are met. MSNJ and New Jersey urologists support this bill, which is a “clean up” to the reforms made to self-referral laws (the Codey Act) in 2009. Lithotripsy was left out of the exemptions in 2009.

2014 Message from MSNJ President, Ruth Schulze, MD

MSNJ –HAPPY 2014!

As we begin a New Year, it seems like a perfect time to look back on 2013 and all that MSNJ has been doing.  At my inaugural last May, I suggested 5 initiatives as part of our strategic plan:

1.                 Outreach for Hospital Staff and Large Group Membership
2.                 Increased Student Participation
3.                 Community Partnership
4.                 Quality Certification for Medical Liability Insurance Reduction
5.                 Coalition Building with Specialty Societies

While we have made progress in all these areas, our mission and battles continue.  But isn’t that a prime reason for MSNJ’s existence- to defend physicians in their professional battles – to be the representative voice of the physician community- to be the watchdog protecting the back of the medical profession.

Scope of practice, out-of-network payments, maintenance of certification, insurance network adequacy, physician exclusions, SGR repeal, ICD-10 conversion, medical liability reform and the prevention of bad legislation are all on MSNJ’s daily “to do “ list.

The MSNJ BOT was recently asked a visioning question at our November board retreat:

If there were no financial or staffing constraints, “I would like my medical society to….”

Board members consistently answered; Increase Effective Communication, Redefine Membership Options, Partner with Community Groups & Organizations, Promote Quality Medicine, Rebrand MSNJ, Create a Public Relations Campaign, Recapture Physician Esteem and ultimately, Increase MSNJ Relevance to Physicians.

These issues are of critical importance to NJ physicians, but interestingly, they are also the same issues which our neighboring states are tackling as well.  Physicians everywhere are struggling with similar issues and feeling equally frustrated and threatened by our flawed medical system.  So much of the daily practice of medicine seems like a fight- insurers, lawyers, legislators, administrators and sometimes even colleagues are all attacking us.  This onslaught has made many physicians jaded and negative. We, the entire physician community, need to recapture the positive side of medicine and reaffirm the healing aspect of our profession.

To that end, I have asked the MSNJ Foundation to help establish a physician led community outreach program targeting adolescent and young adult multicausational  health problems. This public health initiative is modeled after a similar program in Delaware entitled “OBVIOUS”.  I look forward to sharing more details as this program takes shape over the next months.  MSNJ is also introducing a “Women in Medicine” discussion series and CME program this March with a follow-up “Collaborative Health Team” event anticipated for the fall of 2014.  We are also facilitating scheduled quarterly meetings of all specialty societies so that the “Medical Voice” of NJ physicians can be one of unity and well-being.

Such programs are just the beginning of our campaign to revitalize our society and create,

“ The New MSNJ – The Voice of NJ Physicians”.

In February, the BOT will meet for Part 2 of our yearly retreat to establish our 2014 organizational strategic plan.  While there are less than 5 months left in my presidency, our collective mission has no endpoint.  MSNJ’s mission is not a destination but rather an ongoing journey.  Just as in 1766, MSNJ as  the physician voice, is speaking to protect our profession and promote the betterment of public health.  Individually our physician message is important but only heard by a select few.  Together, our physician voice can be powerful ,so let’s “Get Loud” in 2014 as MSNJ becomes “The Physician Voice” in NJ.

– Ruth Schulze, MD
MSNJ President

2014 Medicare Physician Fee Schedule Issues

It was recently brought to our attention that Novitas has yet to post the correct 2014 conversion factor for anesthesia. We also have concerns that the ambulatory surgery center and vaccine fee schedules are not up to date. MSNJ asked Novitas about the timeline for posting the corrected fee schedules. We were advised that they are in the process of updating the anesthesia conversion factor on the website. We are still awaiting information on the ASC and vaccine fee schedules.

Novitas also advised MSNJ that it has loaded the regular 2014 fee schedule and is prepared to accept 2014 claims. Novitas is still working on posting the 2014 physician fee schedule in the file formats that may be imported into billing software. For now, Novitas is posting the files in a basic text only format to give practices an opportunity to review the 2014 fees. Likewise, these fees are not yet available in Novitas’ interactive fee calculator.

We believe that if you bill Medicare less than the 2014 fee schedule amount, Medicare will pay the lesser amount based on past experience. Likewise, in the past, Medicare would not reconsider claims that were paid at a billed amount that is less than the current Medicare fee schedule. We have requested clarification on this issue from Novitas since it appears from the web site that these fees are up to date and physicians may have charged less than what they are entitled to through no fault of their own. To avoid this issue, physicians may want to consider billing Medicare at the practice’s regular fee schedule to ensure that the amount billed is above the Medicare fee schedule amount. Another option is to hold claims until the correct information is posted on the Novitas website.

Please stay tuned to e-News for more information as it becomes available.

Medicaid Expansion Update—Enrollment Glitches

In November, the NJ Medicaid program advised that for individuals applying through the federal Marketplace there would be a lag time between federal and New Jersey approval. It further advised that it was able to handle the lag and that New Jersey had the second highest number of Medicaid enrollments of states using the federal Marketplace.

On December 20^th, a story broke indicating that State officials said that those who applied for health coverage using the federal government’s website are actually unable to be enrolled because the State cannot process the eligibility information from the federal web site.  Per the article, “New Jersey Medicaid said in­formation it received from the federal insurance marketplace for about 25,000 residents who qualify for free health coverage from New Jersey’s program for the poor is ‘unusable.’  Their applications can’t be processed, and they can’t yet be enrolled for coverage that is supposed to begin on January 1.” See more.

But, MSNJ was recently informed that though,

“the flat file sent to NJ Medicaid by the federal Marketplace still is unusable…individuals who applied to the Marketplace between October 1 and December 31, who are verified as Medicaid eligible, will have their coverage backdated to January 1.”

MSNJ immediately asked the Division for guidance and was given the following advice:

-This problem actually affects about 60,000 patients.

-Patients in this category will have letters from CMS stating that they are considered eligible by CMS. This letter only confirms eligibility; it does not place the patient in a plan or provide an ID number. Please be advised that CMS is telling patients that physicians will be able to confirm enrollment, but that is not the case.  The following advice that CMS is giving to patients is not accurate for enrollees in New Jersey:

“If you received a letter telling you that you have been enrolled in Medicaid or CHIP, but you haven’t received an enrollment card from your state agency or from one of its health plans, you should still be able to get health care services. If you need care, show your provider a copy of your eligibility letter. Your provider can verify your enrollment when you go for care.”

– As such, these patients will be treated much like presumptively eligible patients are already treated in New Jersey: they will be considered traditional Fee for Service (FFS) until the State has been able to confirm their eligibility and enroll them in a plan.

-True Medicaid HMO plan enrollment cannot be done until February 1^st, which is the next enrollment period for Medicaid plans.

-While other states are asking patients to re-enroll directly with the State Medicaid program, New Jersey is not doing so.  NJ Medicaid will work to process the applications that came through the federal exchange as soon as possible.

View the CMS FAQs.

Bottom line for our members: You may wish to see a patient who presents a CMS letter, but there is no obligation to do so.  The clients will be considered traditional FFS until they select and are enrolled in an HMO, so a provider would bill Medicaid and get paid the FFS rate.  Once enrolled in a health plan, the client will have to go to a provider within that network.

MSNJ Legislative Update: December 20, 2013

All Payer Claims Databases

The Assembly Health Committee took testimony on the concept of creating an all payer claim database, partly for the purpose of determining proper charges and reimbursement for certain services, particularly out of network services.  MSNJ has testified on existing legislation, stating that APCDs can be a good tool. MSNJ opposes legislation that would create artificial limits on out of network charges and supports improvements on in network issues first. See media coverage here. 

 

Breast Density

The Assembly passed the final version of A2022/S792, which now heads to the Governor’s desk.  MSNJ worked on this bill in great detail. The bill 1) requires insurance companies to cover certain screenings, 2) requires physicians to provide information to  certain patients regarding breast density and 3) requires study of breast cancer risk factors. Radiology facilities must distribute to certain patients a notice that reads as follows: “Your mammogram may show that you have dense breast tissue as determined by the Breast Imaging Reporting and Data System established by the American College of Radiology.  Dense breast tissue is very common and is not abnormal.  However, in some cases, dense breast tissue can make it harder to find cancer on a mammogram and may also be associated with a risk factor for breast cancer. Discuss this and other risks for breast cancer that pertain to your personal medical history with your health care provider.  A report of your results was sent to your health care provider. You may also find more information about breast density at the website of the American College of Radiology.” The bill states that it does not impose a standard of care obligation upon a patient’s health care provider.  The bill requires the Mandated Health Benefits Advisory Commission to prepare a report regarding the implementation and administration of the bill, including analyses of social, medical and financial impact. The bill requires the Department of Health, in conjunction with the Medical Society of New Jersey, to convene a work group to review and report on strategies to improve the dialogue between patients and health care professionals regarding risk factors for breast cancer and breast imaging options. 

 

Self-Referral Laws

The Senate and Assembly have both passed A4222/S2779, which allows practitioner with financial interest in health care service providing lithotripsy to refer patients to that health care service if certain conditions are met. MSNJ and New Jersey urologists support this bill, which is a “clean up” to the reforms made to self-referral laws (the Codey Act) in 2009. Lithotripsy was left out of the exemptions in 2009.  The bill heads to the Governor.

 

Gender Changes on Birth Certificates

The Senate and Assembly have both passed A4097/S2876, which allows more people to change their birth certificates.  To obtain the amended certificate, a person would be required to submit:  1) a form provided by the State registrar of vital statistics and completed by the person’s licensed health care provider which indicates that the person has undergone clinically appropriate treatment for the purpose of gender transition, based on contemporary medical standards, or that the person has an intersex condition; and 2) a certified copy of a court order indicating the person’s name change, if the person has changed his or her name.  Under current law, a person is required to undergo sex reassignment surgery to receive an amended birth certificate.

 

Emergency Generators

The Assembly has passed A4324, which requires that certain health care facilities be either equipped with a generator or be equipped with an appropriate electrical transfer switch and wiring to which a portable generator can be connected in order to provide back-up electrical power to the facility.  Health care facilities included under the provisions of the bill are the following: nursing homes; assisted living facilities; comprehensive personal care homes; pediatric community transitional homes; federally qualified health centers; dialysis centers; hospice in-patient cares; or residential health care centers connected to another licensed facility.  The bill requires that these facilities be equipped with a generator or be generator ready within three years of the effective date of the bill.  The bill also requires the New Jersey Economic Development Authority (“authority”) to offer financial assistance in the form of low-interest loans to eligible facilities for the purchase and installation of a generator, or to make the facility generator ready (the loans are to have an interest rate of not greater than two percent). There is no Senate counterpart.

 

Reconstructive Breast Surgery

The Senate has passed S374, which grants a state sales tax exemption for services prescribed by a doctor in conjunction with reconstructive breast surgery. The procedures, currently subject to the 7 percent tax rate, are utilized to restore the appearance of the breast. The bill addresses a current loophole where insurance providers cover the costs of the procedures but pass on the cost of the sales tax to the patient.  The Assembly version of the bill, A4526, is awaiting final adoption, which will likely happen in lame duck.

 

Physician Loan Redemption

The Assembly Higher Education passed A4507, which establishes a Physician Loan Redemption Program. MSNJ, along with NJ AFP and COTH worked expediently to improve the bill that was passed by the Senate in a skeletal, flawed form.  This is a lame duck priority for policy makers and will reach the Governor’s desk this month. With our input, the bill now bill provides for redemption of eligible qualifying loan expenses for physicians who work for no less than four years at an approved site in the clinical practice of primary care or in the clinical practice of specialized care if the specialty is projected to experience a significant shortage. The bill also provides that the redemption of eligible qualifying loan expenses under the program will be exempt from the program participant’s individual New Jersey State income tax.  Also, in the case of an approved site that is a private primary care physician practice that has hired a loan redemption program participant, the site will have a State income tax exemption for all practice revenues received from providing services under the Medicaid program.

 

Any Willing Provider

The Senate Health Committee took testimony on a bill that would prohibit an NJ insurance company from having exclusive contracts with providers. The bill stems from Horizon’s exclusive contract with LabCorp, but is not limited to lab services.  The Association of Health Plans opposes the bill, stating that keeping narrow networks is a business decision they should have the flexibility to make to control costs (for consumers). Please find MSNJ’s testimony here.

 

Student Eye Injuries

Both houses have passed a bill that requires the Commissioner of Education to develop an educational fact sheet that provides information about sports-related eye injuries.  Each school district and nonpublic school is to distribute the fact sheet annually to the parents or guardians of the students.  The fact sheet is to include, but not be limited to:

      —   a list of the most common sports-related eye injuries and the recognition of the symptoms of those injuries;

      — a recommendation that children seek treatment and advice from a licensed health care professional regarding the appropriate amount of time to delay the return to sports after injury     

—   a recommendation that all children participating in school sports or recreational sports wear protective eyewear;

      —   information concerning the purchase of appropriate protective eyewear; and

      —   any other information the commissioner deems appropriate.

 

Latex Gloves

The Assembly passed a bill that directs the Commissioner of Health to develop a plan to phase out the use of latex gloves in licensed health care facilities and food service establishments to address consumer latex allergies.  The Senate will likely pass the bill soon.

 

Student Health

The Assembly has passed A4415/S2367.  This bill, the “Sudden Cardiac Arrest Prevention Act”, provides student-athletes, parents, and coaches with information on sudden cardiac arrest and establishes protocol concerning removal-from-play for athletes exhibiting symptoms of sudden cardiac arrest.  The following organizations were in support of the bill: NJ Chapter of American College Emergency Physicians, American Heart Association, NJ School Boards Association and the Athletic Trainers Association of NJ.  As previously reported, the Senate passed the bill in June.

 

Mental Health Screenings

The Assembly has passed A3155, which concerns assessments of persons believed to be in need of involuntary commitment to treatment.  The bill requires that an assessment be performed prior to the performance of routine laboratory and diagnostic testing.  If, as a result of the assessment, involuntary commitment to treatment seems necessary, then the routine laboratory and diagnostic testing is to be performed.  (Laboratory and diagnostic testing is currently completed and submitted to screening services before the assessment, so this bill seeks to avoid such testing expenses if the person does not need commitment, and to reduce hospital emergency room waiting times because staff would not have to wait for test results to be reviewed before the assessment is performed.) There is no Senate counterpart.

 

Declaration of Death

Both houses have passed A3586/S2756, which removes the statutory authority of the Department of Health (DOH) and the State Board of Medical Examiners (BME) over medical standards governing declarations of death upon the basis of neurological criteria.  The bill requires that a declaration of death upon the basis of neurological criteria be made by a licensed physician professionally qualified by specialty or expertise, based upon the exercise of the physician’s best medical judgment and in accordance with currently accepted medical standards.  Joint DOH/BME regulations would no longer be needed to set forth currently accepted medical standards (including criteria, tests, and procedures) to govern declarations of death upon the basis of neurological criteria.  If they are used, the regulations concerning the declaration of death upon the basis of neurological criteria may not require the use of any specific test or procedure in the declaration of death upon the basis of such criteria.

MSNJ supports this bill.

 

Breast Milk

The Assembly has passed two bills concerning breast milk. A3702 requires the Commissioner of Health to establish a public awareness campaign to advise pregnant women, new parents, and women who are breast feeding their children about the dangers of casual milk sharing.  The campaign would, at a minimum, provide information on: risk factors associated with casual milk sharing, including disease transmission and contamination from drugs, germs, or chemicals; the federal Food and Drug Administration’s warning against mothers using donated breast milk obtained directly from individuals or other unknown sources; and human milk banks and the procedures they use to select donors and collect, process, store, dispense, or sell donated breast milk.

 

A3703 gives the Department of Health the authority to license and inspect human milk banks, including an inspection of records, files, and other data, and requires the commissioner to promulgate rules and regulations for the operation and maintenance of human milk banks.  The regulations governing human milk banks would include provisions for: staff qualifications; procedures for selecting and screening potential donors; standards for the collection, processing, storage, and distribution of donated breast milk; the maintenance and confidentiality of milk bank records; and license application, issuance, renewal, expiration, denial, suspension, and revocation.

 

Student Asthma

The Assembly Education Committee has passed A954, which creates a 16-member School Asthma Protocol Task Force.  The membership of the task force would include: the Commissioners of Education and Health and 14 public members to be appointed by the Governor as follows: four persons who are parents of children with asthma who are attending a public or nonpublic school; a licensed physician who is a pulmonary specialist; a licensed pediatrician; a certified school nurse; an advanced practice nurse certified in pediatric nursing; a school administrator; a public school teacher; a public school principal or supervisor; a local school board member; a representative of a nonpublic school; and a representative of the American Lung Association.  The task force would be responsible for selecting a school asthma protocol and developing guidelines for the most appropriate and effective means of implementing the selected school asthma protocol on a Statewide basis.  There is no Senate counterpart.

 

Medical Marijuana

The Assembly has passed A4537 which would permit State medical marijuana patients and their primary caregivers to possess, and patients to use, medical marijuana legally obtained from another jurisdiction.  The bill would also permit qualifying out-of-State medical marijuana patients and their primary caregivers to engage in any conduct related to medical marijuana permitted under New Jersey law.  In both situations, the other jurisdiction’s medical marijuana law must be recognized by the Department of Health.  The bill would additionally provide that both parents of a patient who is a minor may serve as the minor’s primary caregivers under the State medical marijuana program, and that a parent who is currently serving as a primary caregiver may concurrently serve as primary caregiver to any minor child of the parent who is a qualifying patient.  There has not yet been action on the Senate counterpart.

www.acr.org

UHC Medicare Advantage Physician Terminations-Organized Medicine Urges that Recent Terminations be Held in Abeyance

MSNJ continues to send appeal letters to CMS and request that it test network adequacy on a case-by-case basis. Please continue to provide information to MSNJ.

MSNJ met with representatives from UHC this week at our offices in Lawrenceville. One of our continuing concerns is how UHC will communicate with its Medicare Advantage members concerning its network reduction initiative and whether Medicare patients will know if their physician will be in the network in 2014. UHC responded that:

Members with recent claims for physicians leaving the network will receive a letter from UHC at least 30 days before the effective date of the termination with instructions to call the customer service number for more information. UHC currently estimates member mailings to take place in early November. Timelines are not yet final for member mailing dates, and are subject to change as data analysis is completed and information finalized.

Consequently, the timing of UHC communication with patients may be as late as the end of the year according to the above information. We are disappointed  because the open enrollment period will have ended and it will be too late for patients to make choices based on the physicians who will remain in these plans. To address this ongoing transparency concern, and the ability of Medicare patients to make informed choices to keep their physician if they wish to, MSNJ joined with the AMA and virtually all of organized medicine requesting that CMS require Medicare Advantage plans to hold all terminations initiated just prior to or during Open Enrollment in abeyance for cost year 2014. Read the letter to CMS which asks that it extend the Medicare Advantage open enrollment period and require plans that have reduced their networks to:

1)     Provide and document that patients received actual and accurate notice of whether their current physicians will be in the 2014 network;

2)     Ensure that patients know that they can retain their physician by choosing fee for service or by choosing a product with an out-of-network benefit if their plan provides one.

3)     Provide physicians information needed to challenge network adequacy based on CMS regulations and extend the appeals deadline until physicians receive such information;

4)     Provide information on how many patients have been impacted and which physicians to state medical societies and the AMA; and,

5)     Direct plans to hold all terminations initiated just prior to or during Open Enrollment in abeyance for cost year 2014.

In addition to our disappointment about UHC’s plans for the timing and communication with patients, UHC also advised this week that it would not carve out an exception for patients who wish to continue to be treated by physicians who may be terminated. UHC will provide us with its continuity of care policy.

UHC advised that physicians should contact their provider representatives to discuss staying in the network. We have posted an updated provider representative list on our web site for members who wish to do so. Since we cannot anticipate how successful these conversations may be, we recommend that physicians appeal from network terminations and supplement pending appeal letters with new information. Visit MSNJ’s web site for appeal pointers. Members should visit the web site for additional resources. We continue to send appeal letters to CMS and ask that it test network adequacy on a case-by-case basis. Please continue to provide information to MSNJ.

House & Senate Committees Issue Framework for Repealing Medicare’s SGR

Late last week, the House Ways & Means and Senate Finance Committees issued a discussion draft on how to repeal the Medicare SGR and reform physician payments. The discussion draft is a summary of the House and Senate’s bicameral framework to repeal and replace the SGR, the first and most significant work from Congress on this decade old problem. Unless Congress acts before January 1, the Medicare physician payment schedule will be reduced on average by 24%.

Key provisions:

• The SGR formula is repealed.
• Annual fee schedule payment updates would be frozen for 10 years; annual positive updates would begin in 2024.
• A new “value-based performance (VBP) payment program” would be used to adjust payments beginning in 2017.  This new VBP program essentially combines all the current incentive and penalty programs (e.g., value-based modifier, meaningful use, PQRS) into one budget-neutral program.  Payments could be increased or decreased significantly, depending on how well a physician scores relative to others on a composite performance score.
• Physicians participating in certain alternative payment models, including the patient-centered medical home, would be exempt from the VBP program.  Revenue thresholds are established for APMs other than the medical home model, and two-sided risk and a quality component would be required to qualify for a 5% bonus in 2016-2021.
• Several proposals to “ensure accurate valuation of services” under the physician fee schedule are made.  Over a three-year period, mis-valued codes would have to be adjusted to achieve 1% in total fee schedule savings to avoid reductions in the total physician payment pool.  In addition, the Secretary of HHS would initiate a data collection effort on resource use requiring selected physicians to submit data (CMS may provide some compensation to physician for doing this) or face a one-year, 10% payment reduction.
• Appropriate use criteria would be applied to certain imaging services; prior authorization requirements would be imposed on outliers.
• HHS would publish utilization and payment data for physicians on the Physician Compare web site.

Comments are sought by the committees by November 12. MSNJ is evaluating and conferring with the AMA on the discussion draft. This will be a topic of debate at the AMA Interim Meeting next week. It is important to note that the draft is not legislation and provisions included in the draft could change.

UHC Terminations of Physicians in Medicare Advantage Plan

In mid-October UHC began terminating physicians in their Medicare Advantage plan. We immediately reached out to UHC when it appeared that the terminations were not isolated, but rather part of a   broad initiative. This week, UHC responded to some of our questions. We are disappointed that there was no warning of this termination initiative which appears to be a significant redesign of the UHC Medicare Advantage network, nationwide, and that information is sparse. For example, UHC would not tell us how many physicians in New Jersey were terminated or whether any specialties were immune to the termination initiative. Yet, UHC assured us that the network had been “tested and retested” for network adequacy and that there would not be a specialty access issue.

Network Adequacy: Obviously, MSNJ has no way of evaluating the impact on the network without more information. Therefore, we are asking all physicians who received termination letters, to provide us with information so that we can better evaluate network adequacy concerns. CMS has agreed to help us with that assessment.

Lack of Transparency: In addition to our network adequacy concerns, we are troubled that patients may be enrolling or re-enrolling in the UHC Medicare Advantage plan now, because seniors are in the middle of open enrollment, believing that they will be able to continue to be treated by physicians who are currently in the plan. UHC agreed to consider our complaint on lack of transparency on the 2014 network, given that seniors are enrolling now based on the current network. It is important to note that patients may change their network selection. CMS will honor the last selection made by the patient by December 7 when open enrollment ends.

Continuity of Care: We expressed our concerns about continuity of care and a disruption of established physician-patient relationships.  We urged UHC to carve out an exception for patients who wish to continue to see their current physician. UHC agreed to consider this request. We believe that patients should have the right to choose their physicians and must know their network status to make those choices.

Discussions with CMS: With a reopening of the federal government, we have contacted CMS about our network adequacy and continuity of care concerns. Our Region 2 office has been facilitating communication with the Region 9 office which is responsible for the UHC Medicare Advantage network. CMS Region 9 is charged with ensuring network adequacy and transparency for Medicare beneficiaries in their selection of a Medicare product. CMS has offered to test areas for network adequacy. Please provide us with information so that we can identify geographical and specialty areas of concern.

What to do: Last week we urged physicians who wished to stay in the Medicare Advantage network to appeal and provided suggestions for those appeals. We will continue to update our advice to members as more information becomes available to us.  Visit our web site for a list of Do’s and Don’ts, Appeal Suggestions, a template letter to inform patients of your imperiled status in the UHC Medicare Advantage Network.

Visit MSNJ’s UHC Webpage for more information.

Save the date for MSNJ’s UHC Termination Update webinar on Tuesday, October 29 at 7:00PM. Details to follow on www.msnj.org.

Walgreen’s Policy on Opioids Leaked to the Press; MSNJ Previously Sought Disclosure

This week a pharmacist employed by Walgreens in Indianapolis leaked the national drug store chain’s policy on filling prescriptions for painkillers. Earlier this year when MSNJ members complained that their patients were being denied refills for pain medications, we sought the policy directly from Walgreens so that we could assist our members who specialize in pain management and other physicians who treat patients with chronic pain. Walgreens would not disclose it to us, or others, based on internal policy. Walgreens did, however, represent that it would reach out to local pharmacies that were refusing to refill prescriptions written by our members.

MSNJ wrote to the Board of Medicine and the Board of Pharmacy alerting them to the situation and expressing our concern about patients being denied access to pain medication. We subsequently convened a panel of stakeholders, including a DEA special agent, former Assistant U.S. Attorney, the Administrator of the NJ Prescription Drug Monitoring Program and physicians who are addiction and pain management specialists, at a Policy & Strategy Panel meeting to find common ground, balancing the risks of diversion and overdose against the legitimate medical needs of patients. We also met with the New Jersey Pharmacists Association in an effort to develop a common guideline on which physicians and pharmacists could agree.  To develop a balanced guideline, we gathered information through a complaint form on our web site. This also allowed us ask Walgreens to reach out to local pharmacies that refused refills.

MSNJ is working with legislators and the Division of Consumer Affairs on legislation to improve the Prescription Drug Monitoring Program. With increased access to and use of the database by pharmacies, physicians and law enforcement, there should be less fear of opioid dispensing by pharmacies. In the larger context of the aim to reduce drug abuse and diversion, MSNJ is also engaging with legislators about proposals for more consumer notice about drug disposal.  We oppose proposals to mandate physicians to check the PDMP.

MSNJ is also working with the New Jersey Pharmacists Association to develop guidelines for pharmacy requests for information from physicians. If pharmacies must ask for information, physicians must have predictability on the scope and triggers of the requests.

Read more.

MNSJ is also partnering with the DEA to educate our members on best practices for opioid prescribing. Please be sure to attend this free event!