Agenda Oct 2: bills remove exclusive physician prescribing powers

SB 542 Background:

Traditionally, there are two ways to get medications: some are over the counter (OTC), others require a prescription (Rx). 

Michigan legislators created a third way about a year ago. For certain prescription drugs, they removed the need for a personal clinician. Instead, the state's MDHHS Medical Director writes a blanket Rx/ standing order for all pharmacies, directing them to dispense certain drugs (EMS opioid reversal drugs, for example).

Around the same time, the FDA removed the prescription requirement for Narcan. The cheapest, most common opioid reversing drug (Narcan) has been available over the counter ever since.

Michigan's response was problematic. Instead of allowing the public to go buy OTC Narcan for themselves, family, friends, or emergencies, the state racked up massive orders of Narcan to stock state police, schools, libraries, bars, and more institutions who might, one day, see a person with a drug overdose.

Predictably, massive demand raised prices and created shortages for those with real-life need.

Now, the state is doubling down.

More accurately, the state is using the legislative process to double down and increase the MDHHS role as drug distributor.

Questions we should ask:

• Why is the state expanding into the pharmacy space?
• Instead, shouldn't we make sure MDHHS is performing its core mission well?

The Senate Fiscal Agency (SFA) captures the facts of this bill.

https://legislature.mi.gov/documents/2023-2024/billanalysis/Senate/pdf/2023-SFA-0542-F.pdf

CONTENT
The bill would enact a new law to allow a person or governmental entity that was distributed an opioid antagonist by the Department of Health and Human Services (DHHS) at no cost to choose the formulation, type of delivery device, method of administration, or dosage of the opioid antagonist that the person or agency received; however, the bill specifies that the ability to choose the formulation or dosage of an opioid antagonist would not apply if that formulation or dosage choice jeopardized the DHHS's receipt of Federal funding.
"Opioid antagonist" would mean naloxone hydrochloride or any other similarly acting and equally safe drug approved by the United States Food and Drug Administration for the treatment of drug overdose.
BRIEF RATIONALE
The bill would give the individuals fighting the opioid crisis a choice about how best to administer opioid antagonists. According to testimony, opioids are the cause of 80% of drug deaths in Michigan and were responsible for the deaths of 3,000 Michigan residents in 2023.
Testimony also indicates that the Centers for Disease Control found that 40% of opioid overdoses occur in the presence of another individual. The ability to request a specific opioid antagonist formulation, device, dosage, or administration method could make the use of an opioid antagonist more successful in the event of an overdose, saving more lives.

FISCAL IMPACT
The bill would have an indeterminate negative fiscal impact on the DHHS and no fiscal impact on local units of government. Currently, the DHHS operates a naloxone portal that provides intranasal and injectable naloxone to health organizations, community organizations, schools, bars and nightclubs, law enforcement, and other relevant agencies at no cost. The bill would expand the type of opioid antagonists available through the naloxone portal by allowing the receiving entity to choose the formulation, type of delivery device, method of administration, or dosage of the opioid antagonist. This would increase costs for the DHHS by potentially increasing the number of opioid antagonists distributed but could also increase costs through the distribution of more costly opioid antagonists. Additionally, the DHHS would face an increased administrative burden by increasing the complexity of requests.
Date Completed: 10-3-24

Each bill typically gets two hearings.

The PT bill is up again this week, along with a few more. The added bills bring new mental health mandates to hospitals, courts, and clinicians.

NAVIGATION NOTE: by scrolling up to the MI Senate - Health Policy tab in the Forum, you can find links to look up bills, committee live video feed, and hearing archives.

Wednesday, October 9, 2024                               12:30 p.m.

AGENDA

 SB 668             Sen. Hertel      Health occupations; physical therapists; prescription requirement for physical therapy treatment; eliminate, and make other modifications to the practice of physical therapy.

 SB 915             Sen. Hertel      Mental health; hospitalization; person requiring treatment; revise, and modify certain procedures for treatment.

 SB 916             Sen. Santana   Criminal procedure; mental capacity; outpatient treatment for misdemeanor offenders with mental health issues; provide for.

 SB 917             Sen. Irwin       Mental health; other; hospital evaluations for assisted outpatient treatment; expand.

 SB 918             Sen. Wojno     Mental health; other; petition for access to assisted outpatient treatment; expand to additional health providers.

 And any other business properly before the committee.

According to the Michigan Legislature, Senate Bill 668 passed in the Senate on 10/23 and is moving to the House of Representatives. 

https://www.legislature.mi.gov/Bills/Bill?ObjectName=2023-SB-0668

This Bill, as well as legally defining the entity of a physical therapist or a physical therapist assistant, alters the wording of legislation regarding the practice of physical therapy to to be focused upon referrals as opposed to prescriptions.

As opposed to a physical therapist receiving a prescription from another health care professional requesting physical therapy for their patient, the legislation now states that they receive referrals. This referral focused language is supposed to place more volition on the part of the physical therapist. According to the bill summary, it is increasing the scope of practice of the physical therapist to, "include examining, evaluating, and testing an individual with a mechanical, physiological, or developmental impairment, a functional limitation, or a disability or other health movement-related condition to determine the cause of the physical therapy problem to be treated."

What should be considered very carefully is how this will effect the amount of paperwork that a physical therapist has to complete on a given day. My mother is a physical therapist, and I too often can think of times where she comes home after a 12 hour day only to complete several more hours of paperwork referred to colloquially among the therapists as "evals". Evaluations of new patients and entering them into the extensive online hospital system is time consuming and draining. We should think extensively about the possible effects of possibly adding more onto the plate of these therapists, especially during the patient referral or evaluation process.

(1) If a physical therapist who is treating a patient upon on the receipt of a referral from a health care professional, as described in section 17820 the physical therapist shall do all of the following, as applicable:

(a) Refer the patient back to the health care professional who made the referral for treatment if the physical therapist has reasonable cause to believe that symptoms or conditions are present that require services beyond the scope of practice of physical therapy.
(b) Consult with the health care professional who made the referral for treatment if the patient does not show reasonable response to treatment in a time period consistent with the standards of practice as determined by the board.

(2) If a physical therapist who is treating a patient without a referral from a health care professional, under the conditions authorized in section 17820, the physical therapist shall do all of the following, as applicable:

(a) Refer the patient to an appropriate health care professional for treatment if the physical therapist has reasonable cause to believe that symptoms or conditions are present that require services beyond the scope of practice of physical therapy.
(b) Consult with an appropriate health care professional if the patient does not show reasonable response to treatment in a time period consistent with the standards of practice as determined by the board.

https://www.legislature.mi.gov/documents/2023-2024/billengrossed/Senate/pdf/2023-SEBS-0668.pdf

MDHHS's Assisted Outpatient Treatment (AOT) is a court-ordered program for individuals suffering from serious mental illness to participate in outpatient mental health treatment for a period of time. This program is intended to help people cope with their illness before it progresses to the point of hospitalization or incarceration. It is a court ordered program because these individuals may not willingly participate in various therapies. These court ordered therapies can include a variety of mandatory treatments, from therapy or case management to medication.

Michigan Senate Bills 915, 916, 917 and 918 all make amendments to this AOT program in a variety of ways:

https://legislature.mi.gov/documents/2023-2024/billanalysis/Senate/pdf/2023-SFA-0915-F.pdf

Senate Bill 915 (S-1) would amend Chapter 4 (Civil Admission and Discharge Procedures: Mental Illness) of the Mental Health Code to do the following:
-- Require a patient to be referred to a community mental health services program if a psychiatrist certified that the patient required assisted outpatient treatment (AOT).
-- Modify the type of health professional that could testify to a patient's need for AOT.
-- Modify the duration of second and third consecutive court orders for involuntary mental health treatment.
-- Allow a court, without a hearing, to convene a conference with an individual who was out of compliance with a court order for AOT and the individual's supervising agency to review compliance with the order.
-- Allow a peace officer to take an individual into protective custody for examination for mental health intervention if the officer had reasonable cause to believe the individual required treatment, instead of if the officer observed conduct that caused the officer to believe such.

Senate Bill 916 (S-1) would amend the Mental Health Code to do the following:
-- Allow a physician, psychologist, or qualified health professional who had personally examined an individual to testify that that individual needed AOT.
-- Allow a prosecuting attorney, defendant, or defense counsel to bring a motion for an assessment to determine if a defendant met the criteria for misdemeanor diversion to AOT at the time a misdemeanor was charged, or any later time before trial.
-- Require a petition for diversion to AOT to be dismissed upon objection by a prosecuting attorney or defendant.
-- Allow a court to enter an order for diversion to AOT for up to 180 days.
-- Allow a court to modify a diversion to AOT, such as by diverting to inpatient hospitalization, if a defendant failed to comply with the AOT.
-- Require misdemeanor charges to remain pending upon diversion to AOT and to be dismissed as a condition of release from AOT.

Senate Bill 917 (S-1) would amend the Mental Health Code to allow an individual who filed a petition asserting that another individual required mental health treatment to request and access mediation to resolve a dispute between the individual requiring treatment and the appropriate community mental health services program related to planning and providing services or support to the individual requiring treatment. In addition, if an individual were required by a court order to receive mental health services due to a petition, the bill would require a hospital to detain that individual for up to 24 hours.

Senate Bill 918 (S-1) would amend the Mental Health Code to allow a hospital director, agency, physician, psychologist, qualified mental health professional, or individual to file a petition for a second or continuing order of involuntary mental health treatment at least 14 days before the expiration of a current order of AOT if the individual receiving treatment were likely to refuse voluntary treatment and needed continued treatment.

The two bills which may prove problematic over time are bills 915 and 918. As SB915 reads on page 11, "If it comes to the attention of the court that an individual subject...is not complying with the order, that the assisted outpatient treatment has not been or will not be sufficient to prevent harm to the individual or to others, or that the individual believes that the assisted outpatient treatment program is not appropriate, the court may...without hearing...modify the order."

The court is able to relax the charge to outpatient therapy or heighten the charge to hospitalization at will, seemingly with any indication they may find. Having a more distinct communication system that requires a healthcare professional as a mediator between the courts and the patient may prove more robust in the long run. 

SB918 is a short bill regarding who can file for the reapplication process of an unwilling person to this program. I found the wording a bit too broad. As the bill states on page 2, "a hospital director, an agency, a mental health professional supervising an individual's assisted outpatient treatment, or an individual 18 years of age or older may file a petition for a second or continuing order of involuntary mental health treatment if the individual continues to be a person requiring treatment and the individual is likely to refuse treatment on a voluntary basis when the order expires."

The inclusion of the word "agency" is particularly what I dislike about the bill. If a patient is in need of help and unwilling to participate in treatment, the request should come from a healthcare professional who cared for them or from a personal friend or family member who has their best interests in mind. When legislation like this decides who and who does not receive mandatory hospitalizations without hearing, agencies seem a bit too impersonal for that process.