07/18/2024

OSMA Mid-Year Advocacy Wrap Up

July has arrived, and as of the last week in June, the state legislators have gone back to their districts for the summer recess to campaign for the upcoming fall elections. The legislative sessions were extremely hectic, with both chambers of the Statehouse moving a record number of bills through committee hearings and floor votes. Your OSMA Advocacy team was actively involved as many of our priority advocacy issues were among those experiencing activity.

As we are halfway through the year, and the elected officials are not expected to return for legislative sessions until this fall, it is time for a check in on our progress with our advocacy agenda and a summary of what we have accomplished so far in this general assembly.

Advocacy Priorities - Updates:

HB 130: Prior Authorization Gold Card

Update - Before the summer recess, HB 130 had another hearing in the House Insurance Committee. A substitute version of this bill has been accepted, in which several compromises were made in order to respond to pushback our coalition has received from the insurance industry and to improve the bill’s ability to move through the legislative process.

As a reminder, HB 130 was introduced in the Ohio House in March 2023 by Rep. Kevin Miller (R-Newark). The bill, if enacted, would create an exemption system that rewards Ohio healthcare providers who consistently receive a high prior authorization approval rate for a specific service in the prior 12-month period. These providers would receive a “gold card” exempting them from the burden of prior authorization for that specific service.

OSMA is leading a large coalition in support of House Bill 130, comprised of dozens of groups - which include numerous other health care organizations - as well as patient advocacy groups. Significant work took place in the fall months of last year and in early 2024 with the sponsor and other interested parties to help move the bill forward. HB 130 will be among OSMA’s highest advocacy priorities for the remainder of the year.

HB 291: Non-Medical Switching

HB 291, regarding non-medical switching, was amended this spring. While the original version of the bill sought to ban non-medical switching entirely, the new version with the amendment allows for potential changes by the insurer if the cost of a medication increases by 5% or higher in calendar year.

This compromise will hopefully help this legislation advance, and thankfully, this change does not significantly diminish the overall positive impact of the bill. Substitute HB 291 would still prevent non-medical switching in the majority of circumstances faced by patients. OSMA will continue its support of this legislation in the fall in order to enact safeguards which will help protect patients and allow them to continue utilizing the best treatments available to them for their conditions.

HB 452: Hospital Violence Prevention

Update – HB 452, which aims to address prevention of hospital violence and contains various provisions regarding training, security plans, and incident reporting, recently passed out of the House Public Health Policy Committee and then out of the full House chamber.

As a reminder, as a part of a coalition of hospital and health care groups, OSMA recently signed on to a letter of support for HB 452 and advocated for its passage. Our coalition will continue to support this proposal during its journey in the Senate.

HB 24: Biomarker Testing

Update – HB 24 was recently voted out of the House Insurance Committee and then out of the full House. It must now advance through the Senate, and OSMA will support that process this fall when legislators are back.

If passed into law, HB 24 would require state-regulated health insurance plans, including Medicaid, to provide coverage for biomarker testing when medically appropriate. Biomarker testing is increasingly used in diagnosis and treatment of a variety of conditions, including cancer. Insurance coverage would, for example, help reduce treatment costs and improve quality of life for Ohioans diagnosed with cancer.

HB 47: AEDs in Schools

Update – HB 47 recently passed out of the Ohio Senate and will now head to the governor’s desk to be signed into law. We have worked in cooperation with the Ohio Chapter of the American College of Cardiology and others on this bill, and we are thrilled to see this legislation cross the finish line this year!

This legislation will require placement of automated external defibrillators in each public and chartered nonpublic school and in each public recreational facility and to require the Ohio Department of Health to develop a model emergency action plan for the use of AEDs.

SB 144: Immunizations

Update – SB 144 has fully passed out of both legislative chambers and is headed to the governor’s desk for signature.

As a reminder, this bill authorizes certified pharmacy technicians and registered pharmacy technicians to administer immunizations in the same manner that pharmacy interns are authorized to do so under current law. Further, it would authorize pharmacists, interns, and technicians to administer immunizations beginning when a child is five, as opposed to the current law age limit of seven. It would also eliminate a requirement that most immunizations for children under age 13 be prescribed in order to be administered by a pharmacist or pharmacy intern.

Although OSMA opposed SB 144 during the legislative process, and because these provisions were largely in place as part of the COVID-19 emergency without notable incident, it was tricky to convince legislators to oppose it, and not possible for OSMA to completely halt the momentum of this proposal.

HB 169/SB 59: Tanning Ban for Minors

Update - This spring, an amendment was added to legislation OSMA has been supporting alongside the Ohio Dermatological Association regarding a ban on use of indoor tanning services for minors. These changes were made in response to significant pushback the sponsors and proponents have heard regarding the concept of parental rights. Now, rather than outright banning indoor tanning use for minors, the bill would require not only parental consent to be given for each time a minor utilizes tanning services, but also for the parent to be present on-site at the time the services are rendered.

We are hopeful that through this compromise, the proposal will receive the boost it needs to move forward in the legislative process, while not sacrificing its core goal by still establishing additional hurdles which highly discourage use of tanning services for individuals under the age of 18.

This legislation has been a goal of ours in tandem with ODA for years with the goal of protecting the youth in our state from exposure to dangerous UV radiation that drastically increases the chance of developing skin cancer. It was originally introduced in this general assembly in the Senate by Senator and physician Terry Johnson, DO (R-McDermott). SB 59’s companion bill in the House, HB 169, is sponsored by Rep. Brett Hillyer (R-Uhrichsville). Dr. Shannon Trotter has testified on behalf of OSMA and ODA in support of both bills on multiple occasions during this legislative cycle. We will continue to advocate for passage of this legislation this fall.

HB 319: Anti-Vaccine Legislation

Update – OSMA and a large coalition of healthcare and business groups have submitted a statement in opposition to HB 319 in order to signal our serious concerns with the proposal. The bill has had several hearings and we will continue to advocate in opposition to its passage, citing the major risks it poses to Ohioans.

As a reminder, this legislation would prohibit discrimination against an individual for the refusal of certain medical interventions for reasons of conscience, including religious convictions. This bill is mainly targeted at vaccinations, and specifically includes vaccine requirements for college admission and employment. It would also, for example, prevent health facilities from implementing policies such as those that require readily-accepted vaccines in the clinical environment (like tuberculosis) or require unvaccinated employees to wear a mask during flu season in certain areas of a hospital.

HB 177: Copay Accumulator

HB 177 has passed out of the House Public Health Policy Committee. It will remain on OSMA’s advocacy priority list this fall as it will need to journey through the Senate if it is to become law. As a reminder, this bill would require health insurers to count amounts paid by or on behalf of covered individuals toward deductibles and cost-sharing requirements.

SB 129: Optometrists - Scope of Practice

Update – OSMA recently gave joint testimony in a committee hearing alongside the Ohio Ophthalmological Society (OOS) in opposition to SB 129, a bill which would allow optometrists in Ohio to perform certain surgical procedures. We are optimistic about how well received our testimony was and will continue to work to ensure that any legislation that makes changes to the eye care model in Ohio demonstrates clear benefit to patients and does not introduce unnecessary risk.

Legislation for Which OSMA Secured Significant Changes:

HB 102: Advanced Practice Respiratory Therapists

Update – A substitute version of this legislation was introduced, and it recently passed out of the House Health Provider Services Committee. The substitute bill was crafted after we provided specific feedback and suggestions for changes which would mitigate our previous concerns.

OSMA has been working on this issue for months alongside the Ohio Society of Anesthesiologists. We initially opposed this legislation, which would establish and license advanced practice respiratory therapists (APRTs) in Ohio. The original version caused us to have numerous serious concerns about its vague language and potential patient risk associated with the proposed scope of practice.

Thanks to our advocacy efforts, we were able to secure significant changes, which include:

Added language which requires that the APRT must practice only in a hospital-based setting;
Added language which requires the APRT to be supervised by a physician and that the supervising physician must be present on location where the APRT is practicing;
Added language which prohibits APRTs from prescribing controlled substances.

These meaningful changes mean that OSMA now has a position of neutrality on HB 102. This is a major advocacy win for OSMA and for physicians across Ohio – and a satisfying conclusion to months of hard work!

SB 60/HB 97: Certified Mental Health Assistants

Update – As you likely remember, OSMA has been opposing SB 60/HB 97 for years- a bill that would create a new mid-level mental health profession - Certified Mental Health Assistant. Our significant concerns have largely been about lack of training and education, lack of specificity, as well as concerns around ensuring proper patient protections. Alongside the Ohio Psychiatric Physicians Association, OSMA has worked tirelessly to oppose the bill since it was first introduced. Through our effective advocacy, we were able to stop the bill from being voted out of the Senate Workforce and Higher Education Committee on three separate occasions and successfully had the bill language removed from the state budget in 2023.

Recently the chair and the sponsor came to us and indicated they would be willing to make significant changes to the bill to address the issues we highlighted, but also indicated continuing to stop the bill in its entirety was not possible. We were asked to identify our top ten major concerns with the bill and our potential solutions to those issues. We are happy to report we were successful in working with the chair, sponsor and committee members to include all 10 items that we requested, which is a huge win for physicians and individuals with mental illness.

OSMA, in partnership with OPPA, was successful in making the following changes:

Added language requiring all CMHA educational programs follow ARC-PA accreditation standards.
Added language that established a committee within the medical board, made up of physicians who are appointed through recommendation from OSMA and OPPA, who will review all CMHA program curriculums before curriculums are sent to Ohio Department of Higher Ed for accreditation.
Added language ensuring all CMHA programs are master’s level programs with a minimum of 30 credit hours.
Added language ensuring all CMHA must have a 4 year under graduate degree before applying for a CMHA program.
Reinstated specifics around 9 additional areas of course work to supplement the mental health education.
Clarified that the scope of practice would be limited to that of the supervising physician and ensuring the service rendered by the CMHA are within the supervising physician’s regular area of practice and expertise.
Removed language that would have given broad authority to the State Medical Board to establish scope of practice expansions.
Added language that requires reimbursement through Ohio’s Medicaid Program.
Added an additional 500 hours under which a CMHA must be under direct supervision.
Removed language that would have allowed a CMHA to pink slip a patient.
Removed language that would have allowed a CMHA to refer a patient to a physical therapist or athletic trainer.
Added language that requires the State Medical Board to promulgate rules around additional quality assurance standards a CMHA will have to follow.

In exchange for making all the amendments requested, OSMA is now neutral on the legislation.

Before legislators left town for the summer, Senate Bill 60 passed out of the Workforce and Higher Education Committee and was then passed out of the full Senate with 20 yes votes and 11 no votes, which means OSMA, OPPA, and our members who participated in our advocacy action grassroots campaign did an excellent job of educating lawmakers about our concerns.

The bill now moves on to the House, where the process will begin again with committee hearings, etc. This process is far from over; the bill will have to be passed out of the House and signed by the governors prior to the end of the year before anything becomes law. Even if the bill makes it across the finish line, there will be a robust regulatory process which OSMA will be actively engaged in. We believe it will be several years before any potential program will even be up and running.

Below is a rundown on what the proposal will now look like in its entirety. As you can see, we believe with all the change we were able to incorporate, our ultimate goal of protecting physicians, but mainly patients, has been accomplished. Please note, this is not a legal analysis, but more of a general overview:

CMHA must be under the supervision, control and direction of a physician. The services rendered by a CMHA must be within their supervising physician’s normal course of practice and expertise.
No physician can supervise more than 5 CMHA at one time (mirroring the language we have for APRNs and Pas).
CMHA must wear a nametag when on duty clearly identifying themselves as a “Certified Mental Health Assistant.”
CMHA will be licensed and regulated by the State Medical Board. Bill includes numerous details about licensure and disciplinary actions the State Medical Board can take. Bill also establishes specific requirements around reinstating a license that has expired or lapsed.
In order to apply for licensure a CMHA must be:

18 years of age;
Have completed a 4 year under graduate degree program;
Have completed 30 credit hours of a CMHA master’s program.
- All CMHA education programs must follow ARC-PA accreditation standards and must include additional education courses in the following:
  - Psychiatric diagnoses included in the diagnostic and statistical manual of mental disorders published by the American psychiatric association;
  - Laboratory studies used in diagnosing or managing psychiatric conditions;
  - Medical conditions that mimic or present as psychiatric conditions;
  - Medical conditions associated with psychiatric conditions or treatment;
  - Psychopharmacology, including treatment of psychiatric conditions, interactions, and recognition and management of drug side effects and complications;
  - Psychosocial interventions;
  - Conducting suicide and homicide risk assessments;
  - Forensic issues in psychiatry;
  - Basic behavioral health counseling;
  - Clinical experiences in inpatient psychiatric units, outpatient mental health clinics, psychiatric consultation and liaison services, and addiction services.
- A committee will be established though the State Medical Board, made up of physicians who are appointed through recommendation from OSMA and OPPA, who will review all CMHA program curriculums before curriculums are sent to Ohio Department of Higher Ed for accreditation.
- CMHA must have 12 hours of CE in Pharmacology every 2 years. Medical Board can establish through rules any other CE requirements they believe a CMHA needs.
- Scope of Practice
  - Ordering diagnostic, therapeutic, and other medical services as appropriate based on a patient's diagnosis that has been made by the supervising physician;
  - Ordering, prescribing, personally furnishing, and administering drugs and medical devices in accordance with the diagnosis that has been made by the supervising physician;
  - Permitted to provide telemedicine services.
- Prohibitions
  - Making an initial diagnosis;
  - Treating a patient for any diagnosis or condition not found in the most recent edition of the diagnostic and statistical manual of mental disorders published by the American psychiatric association, or a similar publication if designated by the board;
  - Engage in electroconvulsive therapy, transcranial magnetic stimulation, or any other intervention designated as invasive by the medical board's rules;
  - Practicing outside of the established scope of practice.
- Supervisory agreements must include:
  - The responsibilities to be fulfilled by the physician in supervising the certified mental health assistant;
  - The responsibilities to be fulfilled by the certified mental health assistant when performing services under the physician's supervision;
  - Any limitations on the responsibilities to be fulfilled by the certified mental health assistant;
  - The circumstances under which the certified mental health assistant is required to refer a patient to the supervising physician;
  - If the supervising physician chooses to designate physicians to act as alternate supervising physicians, the names, business addresses, and business telephone numbers of the physicians who have agreed to act in that capacity.
- Requirements on the supervising physician:
  - Supervising physician must be available for direct communication when supervising a CMHA and must be physically present at the same location as the CMHA for the first 1000 hours of practice;
  - Supervising physician must personally and actively review a CMHA professional activities at least weekly;
  - Supervising physician must reevaluate the patient at least every two years, sooner if the patient’s medical condition as changed;
  - Supervising physician may perform any other reviews of a CMHA they deem necessary.
- Quality Assurance System - Medical Board must establish rules around creating a quality assurance system for CMHA that includes the following:
  - Routine review by the physician of selected patient record entries made by the certified mental health assistant and selected medical orders issued by the certified mental health assistant;
  - Discussion of complex cases;
  - Discussion of new medical developments relevant to the practice of the physician and certified mental health assistant;
  - Performance of any quality assurance activities required in rules adopted by the state medical board;
  - Performance of any other quality assurance activities that the supervising physician considers to be appropriate.
- Physician Delegated Prescriptive Authority:
The certified mental health assistant shall exercise physician-delegated prescriptive authority only to the extent that the physician supervising the certified mental health assistant has granted that authority.
The certified mental health assistant shall comply with all conditions placed on the physician-delegated prescriptive authority, as specified by the supervising physician. If conditions are placed on that authority, the supervising physician shall maintain a written record of the conditions and make the record available to the state medical board on request. The conditions that a supervising physician may place on the physician-delegated prescriptive authority granted to a certified mental health assistant include the following: (i) Identification by class and specific generic nomenclature of drugs and therapeutic devices that the physician chooses not to permit the certified mental health assistant to prescribe; (ii) Limitations on the dosage units or refills that the certified mental health assistant is authorized to prescribe; (iii) Specification of circumstances under which the certified mental health assistant is required to refer patients to the supervising physician or another physician when exercising physician-delegated prescriptive authority; (iv) Responsibilities to be fulfilled by the physician in supervising the certified mental health assistant that are not otherwise specified in the supervision agreement or otherwise required by the legislation.
- CMHA must register with the DEA.
- CMHA can only prescribe a controlled substance in these 3 circumstances:
Buprenorphine, but only for a patient that is actively engaged in opioid use disorder treatment; (state medical board will promulgate rules around restrictions of prescribing buprenorphine);
A benzodiazepine, but only in the following circumstances: (a) For a patient diagnosed by the supervising physician as having a chronic anxiety disorder; (b) For a patient with acute anxiety or agitation, but only in an amount indicated for a period not to exceed seven days;
A stimulant that has been approved by the federal food and drug administration for the treatment of attention deficit hyperactivity disorder, but only if the supervising physician has diagnosed the patient with, or confirmed the patient's diagnosis of, attention deficit hyper activity disorder.
- CMHA must query OARRS when prescribing a controlled substance.
- Medical Board may also promulgate rules around the prescribing of MAT drugs, including limitations and restrictions.
- Bill requires insurance coverage through Ohio’ Medicaid program, it does not require private insurance coverage.

We thank all of our members who became actively engaged in advocacy on this important piece of legislation. We will keep you updated on any activity on SB 60/HB 97 when legislators return in the fall.

SB 196: APRNs - Scope of Practice

Prior to the introduction of this legislation, OSMA was asked to give feedback on the draft bill that would become SB 196. The draft version included hundreds of provisions which affected all physician specialties. OSMA broke down the draft and split up the issues based on impacted specialties and met with physician members and specialty societies to get specific feedback on each of these provisions. Once we had gathered all of our feedback, it was shared with the legislation’s sponsor, Sen. Kristina Roegner, and she was extremely open to our recommendations. She accepted all of our suggested changes to the bill and also ensured that all of the provisions of the bill stated “under the direct supervision of a physician,” so that any “new” authority would have to be granted by the APRN’s supervising physician.

OSMA is thrilled by the results of our hard work and advocacy on this issue and thankful for the sponsor’s willingness to consider and include our recommendations in the bill before official introduction. Due to the thorough and deliberative process which occurred before SB 196 even started its journey in the legislature, OSMA was able to take a Neutral position on this legislation. We will continue to follow it as it recently passed out of the Senate and now must advance through the House.

After the November elections, when the legislators return to the Statehouse, the lame duck legislative session will begin. There will be another rush of activity at this point because any legislation not passed before the end of the year will have to start all over again and be reintroduced next year in the 136^th General Assembly.

Stay tuned for OSMA updates this summer as we gear up for the work to be done this fall and the upcoming elections.

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