Legislative Wrap Up

Adjourning a few days early, the Indiana General Assembly has completed its 2013 legislative session.

Although expanding Medicaid under the Affordable Care Act was much discussed over the past four months of the General Assembly, no legislation was passed on the subject. The Governor and his administration have applied to the Federal Health and Human Services Agency with a request to use the Healthy Indiana Plan model for the Medicaid expansion and is awaiting an answer back.  The legislature gave the Administration the authority to negotiate such a request during the 2011 General Assembly.

If you have questions about the IAFP’s government affairs or are interested in joining our Commission on Legislative and Governmental Affairs please call 317-237-4237.

The legislation below passed out of the General Assembly and is on its way to Governor Pence’s desk for his signature.

Controlled Substances - Senate Bill 246
The Indiana General Assembly is intensely focused on solving the prescription drug abuse epidemic in Indiana. The final legislation tasks the Medical Licensing Board with creating prescribing standards for controlled substances. The legislation also requires a special controlled substance registration for individuals who own clinics that dispense controlled substances but who are not physicians, other licensed health professionals, or hospitals.

Department of Health Matters - Senate Bill 415
There are many provisions in this bill, but the one concerning to the IAFP was the requirement for all immunization providers to input vaccine information into CHIRP (Indiana’s vaccine registry) within seventy-eight hours after a vaccine was administered. IAFP Commission on Legislation Chair Richard Feldman, MD testified in both the House and Senate that CHIRP was onerous for those physicians who still have to input immunization data manually and that the mandate would likely stop some physicians from giving immunizations.

Due to IAFP's concerns, the mandate was scaled back dramatically during the session.  Instead of an immediate effective date, the mandate will go into effect in July of 2015 and will only require those individuals vaccinated under the age of 19 to be reported into CHIRP within 7 days.

At the request of IAFP, the Indiana General Assembly will be studying the issue this summer to see if CHIRP is ready to be mandated. The IAFP will be heavily involved in this study and needs to hear if you have had problems with CHIRP so that we can present them to the legislature en mass.

Control of Ephedrine and Pseudoephedrine - Senate Bill 496
There were four pieces of pseudoephedrine legislation introduced this year. All but one of the bills would have made ephedrine and pseudoephedrine medications prescription only controlled substances. Under Senate Bill 496 an individual can purchase up to 61.2 grams a year, about an 8 month supply if taken daily.

State Budget - House Bill 1001
Every other year the Indiana General Assembly must pass a two-year budget for the state. Currently the Medical Education Board, which provides grants to family medicine residency programs, is funded at $1.9 million. This line item in the budget remained strong this session, n doubt under the direction of Ways and Means Chairman Tim Brown who is also a physician who started his practice in family medicine. Unfortunately, the Indiana Tobacco Prevention and Cessation, which runs the Tobacco Quitline and provides local cessation services, suffered a steep cut from $9 million down to $5 million.

New to the budget in 2013 is a primary care physician scholarship fund, which Marian University College of Osteopathic Medicine will administer. Marian University College of Osteopathic Medicine will select the students to receive yearly scholarships not to exceed $10,000. To accept the scholarships students must sign a practice agreement with Marian University to stay in Indiana and practice in an underserved area as a primary care physician for at least four years. For the 2013-2014 fiscal year the scholarship program is funded at  $1 million for fiscal year 2014-2015 the scholarship program is funded at $2 million.  One of the goals of this scholarship fund is to bring Marian's tuition to a level comparable to state tuition at a public school of medicine.

While the budget does not mandate an expansion of coverage through Medicaid or the HIP program, it does contain a couple relevant provisions.  It requires a transfer in the next biennium of $250 million to the Medicaid Contingency and Reserve account from the state's General Fund.  The Health Indiana Plan (HIP) Trust Fund will also continue to accrue money - another $225 million will be deposited in the fund from cigarette tax revenues over the next two fiscal years (add this to the existing $200 million in the fund).  Add these two sums up, and this amount roughly equates to the amount that the Senate set aside it its version of the budget to cover short term Medicaid expansion costs (the so-called HIP Trust Fund).

There was a last minute proposal to cut Medicaid coverage for pregnant women from 200% of poverty to 133% of poverty (the idea being those women would be eligible for exchange).  However, this effort was tabled for the session after providers expressed grave concerns that some pregnant women would fall through the cracks.

Finally, the budget bill contained language that will require FSSA to submit all State Plan Amendments and Medicaid waiver requests to the State Budget Committee for review.

Direct Access to Physical Therapists - House Bill 1034
Legislation on direct access to physical therapists has been opposed by the IAFP for over a decade. As one of the last states in the country to not have direct access to physical therapists, the pressure was on the statehouse to pass a direct access bill this year.

The final legislation allows patients to access a physical therapist for 24 days without an initial diagnosis and referral from a physician. A referral is required prior to allowing a physical therapist to perform spinal manipulation.

Physician Assistants - House Bill 1099
This legislation removed the requirement for physician assistants to practice one year before being able to prescribe under a supervision agreement physician. Now physician assistants can prescribe immediately once they are under a supervision agreement with a physician that allows them to do so. Physician assistants will still need to have been practicing for one year and at least 1,800 hours to be able to prescribe controlled substances under a supervision agreement with a physician.

The legislation also clarifies that a physician cannot supervise more than two physician assistants at one time. This language was included so that a physician could potentially hire more than two physician assistants, if the physician assistants are working part time.

Midwives - House Bill 1135
For several years there has been an effort to legalize the practice of direct entry midwives in Indiana. Member, Rachel Shockley, DO testified on behalf of the IAFP in the House committee and expressed her concern that the legislation would give patients a false sense of security.

The bill was dramatically amended in the Senate, and the final passed legislation reflects those changes. Under this legislation direct entry midwives must have a physician collaboration agreement on file with the medical licensing board, the physician must review patient charts, the patient must be examined by the collaborating physician at least once in the first and third trimesters, the direct entry midwife must have at least an associates degree in a science field or bachelors degree on top of their midwifery training, and the direct entry midwife must have sufficient liability insurance.

Rule making authority on direct entry midwifery has been granted to the medical licensing board, which will determine how many midwives a physician can collaborate with, the rules for competent practice of midwifery, and rules for when a midwife must refer a client to a physician.

Physician Order of Scope of Treatment Forms - House Bill 1182
The IAFP has been heavily involved with the Physician Order of Scope of Treatment  (POST) legislation over the last two years. The legislation creates a legal medical order on which a patient expresses their medical preferences and a physician documents. The medical order is then valid in all settings, even with first responders. A group of health organizations called the Indiana Patient Preference Coalition, of which the IAFP is a member, will be working to roll out the POST program throughout the state. For more information on the POST concept visit: http://www.iupui.edu/~irespect/POST.html

Immunizations by Pharmacists and Pharmacy Students - House Bill 1464
This legislation would expand the immunizations pharmacists can give through protocol to include Tdap, HPV, Meningitis for individuals over the age of 11. The IAFP was able to limit the Pneumonia immunization through protocol to only those who are 65 and older. Dr. Risheet Patel and Dr. Richard Feldman both testified that the changing Pneumonia standards are complicated and require a physician’s knowledge of the patient’s medical history, and should only be given at the recommendation of a patient’s personal physician.

INSPECT Program - House Bill 1465
This legislation mandates that 100% of Control Substance Registration fees that are collected by the state will go towards funding and improving Indiana’s prescription drug monitoring program INSPECT. This funding is vital so that INSPECT can continue to operate once its federal grant funding expires in 2014.