From abortion restrictions to emergency department caps, state legislatures are having a big say in the practice of medicine.
Over the last year, states have considered major cuts to Medicaid funding, criminal penalties associated with performing abortions, new mandates for continuing medical education (CME), enlarging the scope of practice for certain mid-level providers, and the list goes on.
Not all the bills have made it into law, and doctors have worked overtime to stop or alter these proposals.
"State legislatures probably impact the daily practice of medicine more than [Congress does]," said Dr. Dan K. Morhaim, a practicing internist and delegate to the Maryland General Assembly.
Licensing, CME requirements, loan forgiveness, scope of practice, insurance and hospital regulation, physician payment, and malpractice – each affects day-to-day practice and states have a hand in all of them, said Dr. Morhaim, a Democrat who serves as the deputy majority leader in the Maryland House of Delegates.
Even some of key federal efforts – such as the Affordable Care Act and incentives for the adoption of electronic health records – are being implemented in part by the states, he said.
During the recent Maryland legislative session, physicians scored a big win with the passage of a bill to standardize and automate prior authorization requests. The issue had been on the table for a few years, Dr. Morhaim said, but physicians finally argued successfully that the volume of prior authorization paperwork was driving up costs and slowing down care.
The bill requires payers to establish an online prior authorization system by next summer.
Fighting ED Caps
Meanwhile, in Washington state, physicians worked with lawmakers to stop a policy that would have eliminated Medicaid payments for any emergency department visit deemed "not medically necessary."
Under a proposal put forward by the Washington Health Care Authority in January, Medicaid would have paid for ED visits only if the ED was the medically necessary setting for care.
The Washington State Medical Association, the Washington State Hospital Association, and the Washington Chapter of the American College of Emergency Physicians, joined forces to stop the proposal. The alternative proposal they championed was adopted by the legislature in April.
The alternative calls on hospitals to adopt best practices such as extensive case management for frequent ED users, timely follow-up by primary care physicians, controls on narcotic prescribing, and better emergency visit tracking. Hospitals must implement the best practices this summer and show a reduction in the number of preventable ED visits by January 2013.
Dr. Nathan Schlicher, an emergency physician in Tacoma and the legislative affairs chairman for the state ACEP chapter, said he’s hopeful that the Washington state agreement can be a model for other cash-strapped states looking to cut down on unnecessary ED care.
The key to their success was having an alternative plan to offer to the legislature, Dr. Schlicher said.
"You can’t just say no," he said. "Saying no is not a solution."
In an effort to curb their state’s growing budget deficit, Texas legislators in 2011 cut payments to doctors treating patients eligible for both Medicare and Medicaid by about 20%.
The cut means that fewer and fewer physicians are willing to take on new Medicaid patients, said Dr. Michael E. Speer, president of the Texas Medical Association (TMA) and a professor of pediatrics and ethics at Baylor College, Houston.
As a result, hospitals located in Medicaid-heavy environments are seeing more of these patients – and they are presenting when they are sicker, requiring more care and more expensive care, Dr. Speer said.
That’s the case the TMA will be make to lawmakers when they return to the statehouse in 2013.
"This is not saving money," he said. "This is actually spending more money."
Massachusetts is also looking at ways to control costs as it continues to implement its landmark health reform law.
This year, the Massachusetts legislature is considering bills to curb the growth in health care costs by gradually moving away from the current fee-for-service system. The bills would provide bonus Medicaid payments next summer for providers who choose alternative payment models, such as global payments through an accountable care organization.
The bills also require the use of electronic health records and outline greater public reporting of quality and cost data. One of the bills includes a "luxury tax" on physicians and other providers whose costs exceed certain benchmarks.