May 17, 2018: State Advocacy Update

In a letter to Katherine Thomas, president of the National Council of State Boards of Nursing, the AMA requested that NCSBN remove those provisions of the Advanced Practice Registered Nurse Compact (APRN Compact) that alter state laws related to the scope of practice of APRNs.

The AMA's letter was co-signed by more than 80 state and specialty medical associations. The AMA opposes the APRN Compact because it would inappropriately authorize APRNs who obtain an APRN Compact multistate license to practice and prescribe independent of physician supervision or collaboration in APRN Compact states, regardless of state laws that might require APRNs to have a supervisory or collaborative relationship with a physician.

To date, only three states (Idaho, North Dakota, Wyoming) have joined the APRN Compact; 10 states must join for the APRN Compact to start. Contact Kristin Schleiter ([email protected]), senior legislative attorney, for assistance in defeating APRN Compact legislation in your state.

A new survey of pain medicine specialists found that policies enacted by states, health insurers, pharmacy benefit managers and worker compensation programs are causing patients to go into withdrawal, experience anxiety, depression and increased pain.

The survey was conducted by the American Board of Pain Medicine (ABPM) to help identify how the nation's opioid epidemic is affecting patients with pain and the pain medicine specialists who treat them.

The survey found:

• 83 percent of pain medicine specialists said that they—or their patients—have been required to reduce the quantity or dose of medication they have prescribed;
• 93 percent of pain medicine specialists said that they have been required to submit a prior authorization for non-opioid pain care—with the physicians and their staff spending hours per day on such requests.
• 68 percent of pain medicine specialists said that they have had to hire additional staff to handle the prior authorization requirements.

"Prior authorization in some cases may be understandable to help ensure coverage benefits or coordinate complex care, but when it is used almost universally like this, it seems that the real purpose is to discourage physicians and patients from seeking non-opioid pain care," said ABPM President Mitchell J. Cohen, MD.

Respondents to the survey listed a wide range of non-opioid therapies that have been subject to prior authorization, including:

• Physical therapy limits, psychiatric services, occupational therapy.
• Pain creams and patches (e.g., lidocaine, Lidoderm, Voltaren, topical NSAIDs).
• Non-opioid prescription medications (e.g., Cymbalta, Lyrica, Celebrex).
• Non-opioid pain treatments (e.g., TENS, facet blocks, spinal cord stimulators, epidural injections).

For more information about the survey, contact Mike Slawny, executive director of ABPM at [email protected].

On May 7, New Hampshire became the fourth state approved to implement a work requirement for certain Medicaid beneficiaries. The AMA opposes work requirements as a condition of Medicaid eligibility. As of Jan. 1, 2019, New Hampshire will require adult, non-elderly, non-disabled Medicaid beneficiaries to participate in 100 hours per month of "community engagement activities" such as employment, education, job skills training or community service.

Certain individuals, such as those who are pregnant, medically frail, or caring for a young child, are exempt. The work requirement was a key condition for state legislators who reauthorized the state's Medicaid expansion program this year.

Kansas also requested federal approval to impose a work requirement on certain Medicaid beneficiaries and additionally proposed to limit lifetime coverage eligibility to 36 months even if those work requirements were met.

On May 7, CMS notified the state that it would deny the state's request to impose a 36 month lifetime limit on Medicaid benefits. CMS did not render a decision on work requirements without a lifetime limit. Kansas has not expanded Medicaid under the ACA, and, to date, CMS has only approved work requirements in Medicaid expansion states (Arkansas, Kentucky, Indiana and New Hampshire).

Supporters of Medicaid expansion in Idaho report they have gathered enough signatures to place the measure on the November general election ballot. If approved by voters, Idaho would become the 33rd state to expand Medicaid eligibility to all adults with incomes under 133 percent of the federal poverty level, and approximately 62,000 individuals would gain coverage. Similar efforts to expand Medicaid via ballot initiative are underway in Utah and Nebraska. Montana is also seeking to reauthorize and fund its Medicaid expansion program by ballot this year.

Maine was the first state to pass a ballot measure to expand Medicaid in November 2017. Nearly 60 percent of voters approved the measure; however, Governor Paul LePage has refused to implement the program. On April 30, expansion supporters filed a lawsuit to compel the state to begin implementing the program. Approximately 80,000 low income individuals stand to gain coverage in Maine.

Please contact Annalia Michelman, senior legislative attorney, [email protected] for state Medicaid-related questions.

• May 17, 2018: Advocacy spotlight on Trump Administration releases drug pricing blueprint 
• May 17, 2018: National Advocacy Update 
• May 17, 2018: Judicial Advocacy Update