Highlight on Georgia: State focused on promoting access to care

Georgians have received several pieces of good health care access news lately as the state works ensure that young adults and those living in rural areas get the care they need. Despite constant financial concerns surrounding health care, the state seems to be making it a priority.

Rural Healthcare 180

Rural Healthcare 180 is an effort to promote the new donation program that gives tax credits to both individuals and corporations that make donations to rural hospitals. Kim Gilman, chief executive of Phoebe Worth Hospital and Southwest Georgia Regional Medical Center, said that the hospitals need to upgrade expensive equipment and provide raises to employees.

In total, 48 rural hospitals are eligible to receive the donations. Tax credits will be supplied for donations of up to $4 million, with caps starting at $50 million in 2017 and increasing by $10 million each year for the next two years until program expiration. The potential of additional funding will hopefully address the crisis, as many rural hospitals seem to be set for the same fate as the five that have closed in the past four years.

Mental health center expansion

A new Atlanta campus of a mental health facility will open in October, adding 32 beds for young adults aged 18 to 26. This Rollins Campus, named for a gift received from the O. Wayne Rollins Foundation, is Skyland Trail’s second Atlanta campus. The nonprofit treatment organization operates 48 beds, and 60 percent of patients treated are young adults. Older adults have found Skyland Trail to be a lifeline, including a 63-year-old physician who reported experiencing her first psychotic episode at 56 years of age. She spent five months at Skyland Trail, where she attended to more than her mental health and was able to lose weight through the organization’s nutritional program.

State could be an example for EpiPens® in schools

In the wake of the EpiPen pricing controversy and stories about children in schools denied access to their own pens, Georgia’s approach may offer solutions to ensure safety in situations where students might be unknowingly exposed to food allergens. Karen Harris, mother to three children with severe allergies, founded Food Allergy Kids of Atlanta (FAKA) in 2007 in order to unite families like her own. Her goal is to ensure that this “first-line treatment” is accessible to everyone with any type of allergies.

In 2013, Georgia Governor Nathan Deal (R) signed the Emergency Epinephrine Act, which was introduced by Senator Chuck Hufstetler (R-Rome) and backed by FAKA. The law encourages (but does not require, unlike some states’ legislation) schools to stock EpiPens for emergency use, and authorizes providers to write a prescription in the name of a school. The law also protects anyone who uses the medication in good faith through its good Samaritan provision. A second piece of state legislation allows professionals to prescribe EpiPens for many public entities, including churches, restaurants, and arenas, provided that they register with the state. According to Georgia Health News, only 12 non-school entities have registered, and the article points out that no discount programs are offered to these entities.

Although some are concerned about parents depending on school-stocked pens and failing to provide for their children’s needs, a Georgia school nurse was thankful that they were able to receive donated pens through Mylan’s school program. She noted that in rural settings, quick access to epinephrine is vital when hospitals are some distance away. She has trained 25 teachers to administer the medication in the event of anaphylaxis.

Voters split on ACA, but most say Rx drug costs are unreasonable

The majority of Americans—including Democrats, Republicans, and independents—support several policy changes to control the cost of prescription drugs, according to a September 2016 Kaiser Family Foundation (KFF) Health Tracking Poll. The poll found, however, that Americans remain divided on whether the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) is working well, with 47 percent reporting an unfavorable view and 44 percent reporting a favorable one.

Drug costs

According to a KFF press release, the poll, taken between September 14 and 20, 2016, found that 77 percent of Americans view drug costs as unreasonable, up from 72 percent in an August 2015 poll, and only 21 percent seeing drug costs as reasonable. Despite these findings, the poll found that 73 percent of Americans say paying for their drugs is easy and 26 percent say it is difficult to pay for their drugs. The poll also found that the majority of Americans favor the following policies:

  • 82 percent favor allowing the federal government to negotiate with drug companies to get a lower price on medications for people on Medicare;
  • 78 percent favor limiting the amount drug companies can charge for high-cost drugs for illnesses like hepatitis or cancer;
  • 66 percent favor creating an independent group that oversees the pricing of prescription drugs;
  • 86 percent favor requiring drug companies to release information to the public on how they set drug prices; and
  • 71 percent favor allowing Americans to buy prescription drugs imported from Canada.

The poll, however, also found that only 47 percent of Americans favor eliminating drug advertisements and 42 percent favor encouraging people to buy lower cost drugs by requiring them to pay a higher share if they choose a similar, higher cost drug.

Views of the ACA

Not surprisingly, the poll found that a Democrats largely support the ACA, Republicans largely oppose it, and independents lean unfavorable. When asked if the health insurance marketplace in their own state is working well, 48 percent said it was, while 43 percent said it was not. However, when asked if the marketplaces were working well nationally, the percent responding no grew to 49 percent.

The poll also asked an interesting question regarding the public’s awareness of the uninsured rate under the ACA. When asked if the uninsured rate was at an all-time high or low, only 26 percent knew it was at an all-time low, while 21 percent thought it was at an all-time high. Thirty-eight percent of Democrats and those who thought favorably of the ACA were aware of that the uninured rate was at an all-time low. Only 17 percent of Republicans and those who thought unfavorably of the ACA were aware that the uninsured rate was at an all-time low. Twenty-seven percent of independents were aware that it was at an all-time low.

Voting factors

Finally, in polling completed after the first presidential debate, 67 percent of voters say the candidate’s plan to address the future of the ACA is very important. The percentage of voters who say the candidate’s plan to address the following factors is important to their vote is as follows:

  • the cost of health insurance premiums (60 percent);
  • the cost of health insurance deductibles (55 percent);
  • prescription drug prices (51 percent);
  • the number of uninsured Americans (43 percent);
  • the ongoing opioid epidemic (43 percent); and
  • the Zika virus outbreak (26 percent).

Off-campus outpatient department payment proposal meets industry criticism

CMS’ proposal to revise the outpatient prospective payment system’s (OPPS) method for reimbursing hospitals and physicians for services performed at off-campus locations has received harsh critiques from the industry. Hospitals are concerned that as written, the Proposed rule would require them to enter into financial arrangements with physicians that may otherwise violate fraud and abuse laws. Yet without making such arrangements, hospitals would be required to pay for these off-campus facilities but receive no reimbursement for services.

Proposed rule

The Proposed rule (81 FR 45603) in question is a lengthy one that concerns several programs and entities. One of the many things proposed is implementation of section 603 of the Bipartisan Budget Act, which mandated that certain services furnished off-campus will not be considered outpatient department (OPD) services, but paid under the applicable Part B system. For new off-campus departments that billed for Medicare outpatient services under the OPPS after November 2, 2015, the physician fee schedule will be applied in 2017 for most services.

Hospitals often have multiple departments and facilities spread across an area, and these must meet certain criteria to be considered provider-based. An off-campus outpatient department must be located within a 35 mile radius of the hospital, be held out to the public as part of the hospital, operate its finances fully integrated with the hospital, and provide clinical services integrated with the main hospital.


The American Hospital Association recently published a letter stating its objection, accompanied by a legal memorandum. Calling the policies “short-sighted and unworkable,” the letter states that hospitals will not be provided reimbursement for some Medicare services under the site-neutral policies. The AHA reasons that off-campus departments that have existing financial arrangements with physicians may run afoul of the Stark law (42 U.S.C. §1395nn) and the Anti-kickback Statute (AKS) (42 U.S.C. § 1320a-7b). The AHA believes that CMS must delay site-neutral policy implementation for at least one year in order to address the significant compliance risks.

The accompanying legal memorandum provided by Hogan Lowells dives deeper into the policy implications. The memorandum finds that the new policy may result in physicians receiving payment for expenses to own and operate the facility, even though it is an off-campus department of a hospital. Hospitals are prohibited from providing free goods and services to referring physicians under the AKS and Stark law. Even furnishing items for a physician to use in his practice may be implicated under these laws, if the items reduce a physician’s cost of doing business and are offered with intent to induce referrals. Under the new policy, physicians would receive a benefit of reimbursement for services when they paid nothing for the location in which the services were provided.

Other comments

Lawrence Vernaglia, Foley & Lardner health attorney, offered the opinion that implementing these new payments would impose unreasonable difficulties on outpatient departments that wanted to add new services. He suggested that CMS alter the requirement that grandfathered facilities remain exactly the same as before the rule was implemented and allow departments to make necessary changes. In addition, because site-neutral payments are unlikely, in his opinion, to reduce outpatient department costs, hospitals may decide to close off-campus facilities which could limit access.

America’s Essential Hospitals (AEH) focused on these access issues in its comments, stating that CMS policies “will perpetuate health care deserts” by limiting flexibility and withholding payments to outpatient departments. It emphasized that establishing and sustaining new off-campus facilities is a challenging process when serving vulnerable patients, and that the policy will make new facilities “economically unsustainable.”

These access comments should have been of little surprise to CMS, as on May 19, 2016, a very large group of senators signed a letter addressed to Acting Administrator Andy Slavitt requesting flexibility in applying the new policies. The senators emphasized the necessity of providing hospitals a predictable landscape while providing them the leeway needed to ensure access. The senators specifically asked for flexibility for services provided at dedicated emergency departments (DEDs) as well as off-campus departments that sought to relocate, rebuild, expand, or change ownership in order to meet a community’s needs.

Highlight on Louisiana: State loosens telemedicine requirements for physicians

Effective June 17, 2016, physicians engaging in the practice of telemedicine in the state of Louisiana need not have a physical practice location in the state, nor are they required to enter into an arrangement with a physician who does have a Louisiana practice location to provide for referrals and follow-up care. The new telemedicine law, which also allows physicians to utilize interactive audio without video in certain circumstances, was proposed in reaction to regulations issued by the State Board of Medicine in 2015, which created the physical practice requirement.

In-state practice location

In November 2014, the American Telemedicine Association (ATA) issued comments to the Board, stating that its then-proposal to require physicians to maintain a physical practice location or enter into arrangements with in-state physicians “would be the most anti-telemedicine in the nation, especially for patients needing medical experts outside the borders of Louisiana or in an [sic] natural disaster,” and went on to opine that the proposal “reflect[ed] more of a concern of protecting economic markets rather than having anything to do with providing health services to the residents of Louisiana.”

The new law eliminates the physical practice requirement but retains the Board rules stating that physicians need not conduct an in-person physical examination or patient history prior to providing telemedicine services as long as they hold unrestricted licenses to practice medicine in the state and have access to patient records with consent.  However, it adds requirements for doctors to create a medical record for each patient and make it available to the Board upon request and, when necessary, to provide a referral to an in-state physician or otherwise arrange for in-state follow-up care.

Audio communications

The 2015 Board rules also required physicians to provide telemedicine services via simultaneous two-way video and audio communications. The new law, however, allows doctors to utilize interactive audio communications without video communication, provided that they first access and review a patient’s records and determine that they can meet the same standard of care as if they were providing face-to-face services.

Controlled substances

The new law did not affect existing Board rules prohibiting physicians from prescribing controlled substances via telemedicine services unless the physician has had at least one in-person, in-state medical visit at a practice location within the past year, the prescription is entered for a legitimate medical purpose, it conforms with the in-person standard of care, and is otherwise permitted by state and federal laws and regulations.