New law stops potential criminalization of EMS ‘standing orders’ for timely controlled-substance use

A new bipartisan law, the Protecting Patient Access to Emergency Medications Act of 2017, P.L. 115-83, signed by President Trump on November 17, 2017, amends the Controlled Substances Act (CSA) (P.L. 91-513) to clarify that emergency medical services (EMS) professionals (including nurses, paramedics, and emergency medical technicians) are able to continue administering controlled substances (contained in schedules II, II, IV, or V) to critical patients, such as pain narcotics and anti-seizure medications, pursuant to standing (written medical protocol) or verbal (oral directive) orders when authorized by state law (Protecting Patient Access to Emergency Medications Act of 2017, P.L. 115-83, enacted November 17, 2017).

It has been a long-standing practice for medical directors of EMS agencies to write standing orders for the administration of controlled substances by EMS professionals. As reported by Emergency Physicians Monthly, in a January 2015 meeting with the National Association of EMS Physicians (NAEMSP) Executive Committee to discuss possible EMS regulations, the Drug Enforcement Administration (DEA) stated its position that the CSA only allows for patient-specific orders for controlled substances and that it is illegal for EMS agencies to deliver any controlled substances under written medical protocols or standing orders. Therefore, absent this new legislation, it was the position of the DEA that any regulations concerning EMS agencies would be required to prohibit the continued use of standing orders for EMS professionals.

The law also allows EMS agencies the option of having a single DEA registration in each state where the EMS agency administers controlled substances, in lieu of requiring a separate registration for each location of the EMS agency within the state, as long as certain transportation, storage, re-stocking, and recordkeeping rules for controlled substances are followed by the EMS agency. The act further provides that a hospital-based EMS agency may use the DEA registration of the hospital to administer controlled substances without an additional registration of its EMS agency.

The law was introduced as H.R. 304 in the House of Representatives by Reps. Richard Hudson (R-NC) and G.K. Butterfield (D-NC). The Senate version, S. 916, was introduced by Sens. Bill Cassidy (R-La) and Michael Bennet (D-Colo). H.R. 304 initially passed the House by a vote of 404-0 on January 9, 2017. It passed the Senate, as amended, by unanimous consent, on October 24, 2017.

Preventing and fighting surprise medical billing: steps consumers should take

Thirty-two percent of insured individuals who had problems paying medical bills reported receiving care from an out-of-network provider that their insurance did not cover, while 69 percent of those individuals said they were not aware that the provider was not in their plan’s network when they received the care, according to a Kaiser Family Foundation (KFF) survey published in January 2016. Betsy Imholz, special projects director and a surprise medical bill expert at Consumer Reports, noted in a January 17, 2017, article that “the problem is only growing worse as our healthcare system grows more complex and more insurance companies narrow the network of doctors they contract with or shift to insurance plans that eliminate coverage for out-of-network services.”

What is a surprise medical bill?

A medical bill that an insured individual receives from an out-of-network provider when the individual is unaware that the provider is out-of–network is referred to as a “surprise medical bill.” Out-of-network providers may charge patients whatever they choose and may bill the patient for the amounts that were not paid by the patient’s health plan, referred to as a “balance bill.”

According to a March 2017 KFF report on surprise medical bills, such bills may arise from an emergency when the individual does not have the ability to select providers. Often, emergency room (ER) physicians do not participate in the same health plan networks as the hospitals where they work. In addition, the patient may not have had the ability to choose the hospital or the ambulance provider. In situations when a patient receives planned care, such as a planned surgery from an in-network provider (for example, a hospital or ambulatory surgical center), other providers involved in the surgery may not be in the same network. In many nonemergency situations, the in-network provider rather than the patient arranges for the other providers participating in the procedure or treatment. Such providers may include anesthesiologists, radiologists, pathologists, and surgical assistants.

What consumers can do

Individuals can prevent surprise medical bills by avoiding receiving services from out-of-network providers, when possible, and fight surprise medical bills after receiving them. A Center on Health Insurance Reforms (CHIR) report identified the following steps for patients to take to prevent unexpected charges:

  • Use provider directories and other plan provided information to identify in-network providers;
  • Ask providers if they are in the patient’s health plan network;
  • After receiving a balance bill, the patient should review the plan’s explanation of benefits and notices about consumers rights;
  • Before paying a balance bill, the patient should contact the health plan and the provider to find out if the plan is willing to pay the bill and/or if the provider will accept a lesser amount; and
  • Contact the state insurance department to see if there is a remedy under  state law.

Additional tips for patients were addressed in an April 6, 2017, article in Consumer Reports written by Donna Rosato. In cases of emergency care or if ambulance service is needed, Rosato recommended the individual to ask the first responders or ER doctors to provide documentation confirming that the individual had no choice and transport by ambulance was medically necessary. She noted, however, as a preventive measure, that individuals find out, before needing to go to an ER, which nearby hospitals are in-network and which ER physicians are in-network. Then, in an emergency, if possible, the individual can request to be taken to an in-network ER. In nonemergency situations, such as a planned surgery, Rosato also suggested that individuals obtain a list from the doctor’s billing staff (and hospital) of other providers that may be part of the procedure or treatments such as an anesthesiologist, radiologist, and pathologist. Then contact the insurance plan and ask if the providers identified are in-network. If the providers are out-of-network, the individual should notify the attending physician and request providers who are in-network.

Personal health care spending from 1996 to 2013 analyzed

Despite the increase in health care spending in the United States, not enough is known about how private and public spending varies according to condition, age and sex group, and type of care. An investigative study of government budgets, insurance claims, U.S. government records, and facility and household surveys, published by JAMA, concluded that from 1996 to 2013 there was $30.1 trillion in personal health care spending for 155 separate conditions, with spending on diabetes, ischemic heart disease, and low back and neck pain accounting for the highest amounts of spending.

Conditions and type of care. The 155 conditions examined included cancer, which was broken down into 29 separate conditions. For the top three spending conditions, the study made the following findings for 2013:

  • Diabetes had the highest health care spending in 2013, with an estimated $101.4 billion in spending, including 57.6 percent spent on pharmaceuticals and 23.5 percent spent on ambulatory care.
  • Ischemic heart disease had the second-highest amount of health care spending in 2013, with estimated spending of $88.1 billion.
  • Low back and neck pain had the third-highest amount of health care spending in 2013, with estimated health care spending of $87.6 billion.

The study’s analysis of spending from 1996 through 2013 found that personal health care spending increased for 143 of the 155 conditions. Additional study findings regarding spending increases from 1996 through 2013 include:

  • Low back and neck pain spending increased by an estimated $57.2.
  • Diabetes spending increased by an estimated $64.4 billion.
  • Emergency care spending increased 6.4 percent.
  • Retail pharmaceutical spending increased 5.6 percent.
  • Inpatient care spending increased 2.8 percent.
  • Nursing facility spending increased 2.5 percent.

Age and spending. The study found that spending among working-age adults, totaling an estimated $1 trillion in 2013, was attributed to many conditions and types of care. Among persons 65 years or older, an estimated $796.5 billion was spent in 2013, with 21.7 percent occurring in nursing facilities. The smallest amount of health care spending was found to be for persons under age 20 years, with an estimated at $233.5 billion spent, or only 11.1 percent of total personal health care spending in 2013.

Age, sex and spending. The study found that the greatest spending was for individuals between 50 and 74 years, with spending highest for women 85 years and older. Because life expectancy for men is lower, the study found less spending by men in the 85 years and older age group.

Estimated spending differed the most between the sexes from age 10 to 14 years, according to the study, when males have health care spending associated with attention-deficit/hyperactivity disorder, and at age 20 to 44 years, when women have spending associated with pregnancy and postpartum care, family planning, and maternal conditions. Together the study estimated that these conditions constituted 25.6 percent of all health care spending for women from age 20 through 44 years in 2013. Without this spending, the study concluded that females spent 24.6 percent more overall than males in 2013.

Conclusion. The study concludes that this information is important because it may have implications for efforts to control U.S. health care spending.