ANNUAL MEETING 2018
DELEGATE HANDBOOK
10/12/2018 Page 1 Date: October 2018
To: House of Delegates Members
From: Arthur J. Vayer Jr., M.D., Speaker Alan H. Wynn, M.D., Vice Speaker
Subject: 2018 Meeting of the MSV House of Delegates
Welcome to the 2018 Annual Meeting and the House of Delegates. Our efforts will be enhanced by your fullest participation. Your Speakers stand ready to assist you in your deliberations.
Items for consideration will be introduced on Friday, October 19, 2018. Full testimony on these items will be received from any member of the MSV at the Reference Committees on Friday, October 19, 2018. Please attend and participate. This is where the strength of the decisions of the House originates. We recommend that you become familiar with the reports and resolutions. Reports and Resolutions have been posted on the MSV web site at https://www.msv.org/rcreports. The agenda for each session of the House can be referenced in this handbook.
Finally, as the meeting progresses, be mindful of your obligation to report our actions and decisions and their rationale back to your constituents.
We look forward to working with you in Roanoke.
10/12/2018 Page 2 MEMORANDUM
Date: 2018
Memo to: Presidents, Secretaries and Executive Directors of Component and Specialty Societies Academic Medical Schools Health Systems
From: Arthur J. Vayer Jr., MD, Speaker Alan Wynn, MD, Vice Speaker
Subject: Call for Resolutions 2018 Annual Meeting of the Medical Society of Virginia House of Delegates
Resolutions should be submitted online by September 4, 2018 to the MSV House of Delegates to be considered regular business. Visit http://www.msv.org/submit-resolution to submit a resolution and for additional materials. Late resolutions, submitted after September 4, 2018 will be subject to consideration under the Rules of Procedure. If your society has a scheduled meeting that occurs after September 4, 2018, your society may submit a resolution within 7 days of the meeting. This resolution will not be considered late, if submitted with the 7 days. Please email [email protected] to let us know. Receipt of resolutions will be confirmed by return e-mail message. If you do not receive a confirmation, your resolution has not been received.
To be considered at the MSV House of Delegates, all resolutions must meet the following criteria:
Identify who is submitting the resolution and include a point of contact; Submitted in final form - resolution(s) submitted on behalf of a society must be approved by the society; Sponsor(s) or their designees must attend the Friday Reference Committee meeting to speak to the resolution; Changes or additions to MSV policy should refer to the Policy Compendium with appropriate policy numbers, strikethroughs, and underlines; and Supporting background material may be submitted electronically with the resolution.
Questions: Email [email protected] or call 800.746.6768.
10/12/2018 Page 3
HOUSE OF DELEGATES - First Session Agenda Friday, October 19, 2018, 10:00 am
Call to Order Virginia Delegation to the The Speakers American Medical Association Update Randolph J. Gould, M.D. Pledge of Allegiance and Claudette Dalton, M.D. Meeta Prakash, Virginia Tech Carilion 2nd year student Credentials Committee Report Co-President of the Virginia Tech Mark Monahan, M.D. Carilion MSV Chapter and Vice Chair of the MSV Medical Student Section Request for approval of the 2017 MSV Events Committee House of Delegates sessions minutes Alan Wagner, M.D. Invocation Patricia A. Pletke, M.D. Rules Committee Report John Sweeney, M.D. Presidential Address Kurt Elward, M.D. Consent Calendar: Informational Reports (Any item is eligible for extraction; MSVPAC Awards Reports will be posted online) Peter Kemp, M.D. The Speakers
In Memoriam 1. Actions of the 2017 House of Delegates The Speakers 2. MSVPAC Report 3. Medical Student Section Report Speaker Remarks 4. AMA OMSS Report The Speakers 5. Virginia Board of Medicine Annual Report Introduction of Guests 6. Physician Assistant Section Report The Speakers
Recognize New Delegates MSV Board Actions on the 2017 The Speakers MSV House of Delegates Resolutions Recognize 50 Year The Speakers Medical School Graduates The Speakers New Business The Speakers Secretary of Health and Human Resources Announcements Secretary Daniel Carey, M.D. The Speakers
Recess until 8:30 am Sunday, October 21, 2018
10/12/2018 Page 4
HOUSE OF DELEGATES - Second Session Agenda Sunday, October 21, 2018, 8:30 am
Call to Order The Speakers Installation of Officers, Directors, Associate Directors and Membership Introduction of Guests Randolph J. Gould, M.D. The Speakers Incoming President Remarks MSV EVP Remarks Richard Szucs, M.D. Melina Davis-Martin Election of the 2018-2019 Credentials Committee Report Nominating Committee Mark Monahan, M.D. The Speakers
Nominating Committee Report Reference Committee Reports Claudette E. Dalton, M.D. a. Reference Committee 1 Ann Thomas, MD Election of Officers and Directors The Speakers b. Reference Committee 2 a. President-Elect Jonathan Schaaf, M.D b. Speaker of the House c. Vice-Speaker of the House c. Reference Committee 3 d. Directors for two-year term – Atul Marathe, M.D. Districts 2, 6, 8, 10, and Academic Announcements e. Directors for one-year term – The Speakers Resident and Medical Student f. Associate Directors for two-year Adjournment term – Districts 2, 6, 8, 10, and The Speakers Academic g. Associate Directors for 1-year term – District 3, Resident, and Medical Student h. Delegates and Alternate Delegates to the AMA
10/12/2018 Page 5 American Institute of Parliamentarians Standard Code of Parliamentary Procedure Basic Rules Governing Motions Order of Applies to what Can have other motions Rank/Precedence1 Interrupt Second Debate Amend Vote other motions? applied?5 Renewable Privileged Motions 1. Adjourn No Yes Yes2 Yes2 Majority None Amend, Close Debate, Yes Limit Debate 2. Recess No Yes Yes2 Yes2 Majority None Amend, Close Debate, Yes6 Limit Debate 3. Question of Privilege Yes No No No None None None Yes Subsidiary Motions 4. Table No Yes No No 2/3 Main Motion None No 5. Close Debate No Yes No No 2/3 Debatable None Yes Motions 6. Limit Debate No Yes Yes2 Yes2 2/3 Debatable Amend, Close Debate Yes6 Motions 7. Postpone to a Certain No Yes Yes2 Yes2 Majority Main Motion Amend, Close Debate, Yes6 Time Limit Debate 8. Refer to Committee No Yes Yes2 Yes2 Majority Main Motion Amend, Close Debate, Yes6 (or Board) Limit Debate 9. Amend No Yes Yes3 Yes Majority Rewordable Close Debate, Limit No6 Motions Debate Main Motions 10a. The Main Motion No Yes Yes Yes Majority None Subsidiary No 10b. Specific Main Motions Adopt in-lieu-of No Yes Yes Yes Majority None Subsidiary No Amend a Previous No Yes Yes Yes Same Vote Adopted MM Subsidiary No Action Ratify No Yes Yes Yes Same Vote Adopted MM Subsidiary No Recall from No Yes Yes2 No Majority Referred MM Close/Limit Debate Committee No Reconsider Yes4 Yes Yes2 No Majority Vote on MM Close/Limit Debate No Rescind No Yes Yes No Same Vote Adopted MM Subsidiary; not amend No
10/12/2018 Page 6 Incidental Motions (non-ranking within the classification) Motions No order of Applies to what Can have other Rank/Precedence Interrupt Second Debate Amend Vote other motions? motions applied? Renewable Appeal Yes Yes Yes No Majority7 Ruling of Chair Close/limit debate No Suspend the Rules No Yes No No 2/3 Procedural Rules None Yes Consider Informally No Yes No No Majority Main Motion or None Yes Subject Requests Point of Order Yes No No No None Procedural error None No Inquiries Yes No No No None All motions None No Withdraw a Motion Yes No No No None8 All motions None No Division of a Question No No No No None8 Main Motion None No Division of Assembly Yes No No No None8 Indecisive Vote None No
MM = Main Motion
1Motions are in order only if no motion higher on the list is pending. 2Restricted 3Not debatable when applied to undebatable motion 4Member may interrupt proceedings, but not a speaker 5Withdraw may be applied to all motions 6Renewable at discretion of presiding officer (chair) 7Tie or majority vote sustains the ruling of the presiding officer; majority vote in negative reverses the ruling 8If decided by assembly (by motion), requires a majority vote to adopt
American Institute of Parliamentarians (888) 664-0428 www.aipparl.org [email protected]
10/12/2018 Page 7 Annual Meeting of the Medical Society of Virginia
Minutes of the First Session of the House of Delegates Friday, October 20, 2017
The 2017 session of the Medical Society of Virginia House of Delegates convened on Friday, October 20 at Hilton Norfolk the Main in Norfolk, Virginia.
Speaker Art Vayer, M.D. called the 170th annual meeting to order at 10:01 a.m. The Pledge of Allegiance to the flag was led by Mr. Kenneth Qui, and the invocation was given by Dr. Edilberto Pelausa.
Dr. Joel Bundy, MSVPAC member, presented the Clarence A. Holland Award to Dr. Hugh Bryan and Dr. Barbara Allison-Bryan and the District Achievement Award to MSV District 3. Dr. Harry Bear accepted the award on behalf of District 3.
An “In Memoriam” of those MSV members who have passed in the last year was projected.
Guests were acknowledged by the Speakers and included: Dr. Barbara Allison-Bryan, President, Virginia Board of Medicine, Mr. Chris Bailey, Executive Vice President, Virginia Hospital and Health Care Association, Dr. William Hazel, Secretary of Health and Human Resources of the Commonwealth of Virginia and former President of MSV, and Dr, Maurice J. Oakley, President, Kentucky Medical Association.
The Speakers recognized new delegates, 50-year medical school graduates, and MSV members who have been members of the Society for 20 years or longer.
Dr. Bhushan Pandya, Outgoing MSV President, shared remarks regarding his year as president.
Dr. William Hazel, Secretary of Health and Human Resources for Virginia provided an update.
Dr. Siamak Kazemi, and Dr. Peter Zedler, Co-Chairs of the Credentials Committee, reported that a quorum is present with more than twenty-five (25) percent of the number of delegates allowed representing at least ten ((8) component districts are present.
Dr. Alan Wagner, MSV Secretary-Treasurer, asked for comments on minutes from the 2016 meetings of the House of Delegates. Hearing none, the minutes were approved without objection.
Dr. Larry Mitchell, Rules Committee Chair, recommended adoption of the proposed Rules of Procedure provided. The Rules of Procedure were adopted by unanimous vote. There were no late resolutions presented this year.
The following informational reports were presented as consent calendar items and filed with the one extraction. The Medical Student Section report was extracted for placement on the second session of the House‘s consent calendar being held Sunday, Oct. 22.
Actions of the 2016 Session of the MSV House of Delegates MSVPAC Report AMA OMSS Report Virginia Board of Medicine Annual Report Physician Assistant Section Report
After hearing no discussion, the Board Actions on 2016 Annual Meeting Resolutions report was filed
The first session of the House of Delegates recessed at 10:46 a.m.
10/12/2018 Page 8 Minutes of the Second Session of the House of Delegates Sunday, October 22, 2017
Speaker Art Vayer, M.D. called the meeting to order at 8:30 a.m.
Guests were acknowledged by the Speakers and included: Dr. Barbara Allison-Bryan, President, Virginia Board of Medicine, Mr. Chris Bailey, Executive Vice President, Virginia Hospital and Health Care Association, and Dr. Barbara McAneny, President-elect, American Medical Association.
Dr. Peter Kemp, Chair of the MSV PAC presented the Advocacy Award to Dr. Ann Thomas and the founders of the Lynchburg Opioid Coalition.
Ms. Melina Davis-Martin, Executive Vice President, addressed the House.
Dr. Siamak Kazemi, and Dr. Peter Zedler, Co-Chairs of the Credentials Committee, reported that a quorum is present with more than twenty-five (25) percent of the number of delegates allowed representing at least ten ((8) component districts are present.
Ms. Samantha Hay, Chairwoman of the Medical Student Section recapped the progress of the growing medical student section, their recent accomplishments and commitment to the House of Medicine.
Dr. Barbara McAneny, President-elect, American Medical Association, provided and AMA update.
Dr. Claudette Dalton, Chair of the Nominating Committee, presented the Nominating Committee Report. A motion was made to accept the nominations and the following were elected by unanimous vote:
OFFICERS President-Elect Richard A. Szucs, M.D. Speaker Arthur J. Vayer Jr., M.D. Vice Speaker Alan H. Wynn, M.D.
DIRECTORS (Elected for 2-year term) District 1 Timothy L. Raines, M.D. District 3 John F. Butterworth IV, M.D. District 3 Peter A. Zedler, M.D. District 5 Jacqueline M. Fogarty, M.D. District 7 Mohit Nanda, M.D. District 7 Michael S. Amster, M.D. District 9 Larry G. Mitchell, M.D. Foundation Cynthia C. Romero, M.D.
DIRECTORS (Elected for 1-year term) Resident J. Mark Hylton, M.D. Medical Student S. Kathleen Carlson
ASSOCIATE DIRECTORS (Elected for 2-year term) District 1 James R. Dudley, M.D. District 3 Clifford L. Deal III, M.D. District 5 Pradeep K. Pradhan, M.D. District 7 Samuel D. Caughron, M.D. District 9 W. David Kiser, M.D.
ASSOCIATE DIRECTORS (Elected for 1-year term) Resident Lee Ouyang, M.D. Medical Student Meredith Johnson
AMA DELEGATES (Elected for 2-year calendar terms) Claudette Dalton, M.D. David A. Ellington, M.D. Randolph J. Gould, M.D.
10/12/2018 Page 9 Hazle S. Konerding, M.D.
AMA ALTERNATE DELEGATES (Elected for 2-year calendar terms) Joel T. Bundy, M.D. Clifford L. Deal III, M.D. Bhushan H. Pandya, M.D.
Dr. Richard Szucs was elected unanimously as MSV president-elect.
Dr. Barbara McAneny, President-elect, American Medical Association, conducted the installation of officers.
Dr. Kurtis Elward, Incoming President, addressed the House.
The Nominating Committee was presented for election and elected by unanimous vote and included the following members:
District 1 Hugh M. Bryan III, M.D. District 2 Stuart Mackler, M.D. District 3 Hazle S. Konerding, M.D. District 5 Mukesh Nigam, M.D. District 6 David A. Ellington, M.D. District 7 Claudette E. Dalton, M.D. District 8 Carol S. Shapiro, M.D. District 9 Larry G. Mitchell, M.D. District 10 Russell C. Libby, M.D. Academic Karen S. Rheuban, M.D. AMA Advisor Randolph J. Gould, M.D. Advisor Edward G. Koch, M.D. (2016-2018) Advisor Bhushan H. Pandya, M.D. (2017-2019)
A special resolution to commemorate the 20 year anniversary of the Medical Society Virginia’s Medical Student Section was presented to Dr. Cliff Deal by Samantha Hay.
Dr. Michael Menen presented the reports of Reference Committee 1 and Dr. Atul Marathe, presented the reports of Reference Committee 2. The final actions of the House of Delegates for all resolutions are attached to these minutes.
The 2017 Annual Meeting of the House of Delegates of the Medical Society of Virginia adjourned at 11:30 a.m.
10/12/2018 Page 10 SUMMARY OF ACTION ADOPTED
17-101: MEDICAL SOCIETY OF VIRGINIA PROPOSED 2018 BUDGET 17-103: MSV POLICY COMPENDIUM UPDATES 17-204: GUN VIOLENCE RESTRAINING ORDERS 17-210: OPPOSING HEALTH PLANS RESTRICTING MEDICALLY NECESSARY CARE
ADOPTED AS AMENDED OR SUBSTITUTED
17-102: MSV 2017 POLICY COMPENDIUM TEN YEAR REVIEW 17-106: RESOLUTION TO IMPROVE OBESITY MEDICARE & INSURANCE COVERAGE 17-107: AMA POTENTIAL RESOLUTION: I-17 FEES FOR TAKING MAINTENANCE OF CERTIFICATION EXAMINATION 17-111: REVISION OF "GOOD SAMARITAN" STATUTES FOR TEAM PHYSICIANS 17-112: HUMAN TRAFFICKING 17-205: MEDICAID REFORM FOR ADULTS RECEIVING SOCIAL SECURITY DISABILITY INCOME 17-206: RESOLUTION ON TOBACCO CONTROL AND HEALTH CARE IN VIRGINIA 17-207: RESOLUTION TO IMPROVE STEP THERAPY IN VIRGINIA 17-209: RESOLUTION TO IMPROVE UPON THE CURRENT PRIOR-AUTHORIZATION LAW IN THE STATE OF VIRGINIA 17-211: RESOLUTION REGARDING THE WITHDRAWAL OF INSURANCE PROVIDERS FROM THE ACA AND INDIVIDUAL MARKETPLACE 17-212 E-PRESCRIBING OF SCHEDULE II MEDICATIONS
REAFFIRMATION OF EXISING POLICY 17-201: MEDICAID EXPANSION /MSV POLICY 290.008 MSV EXISTING POLICIES 145.001, 145.002, AND 145.003
REFERRED TO BOARD OF DIRECTORS
17-105: TRUTH IN ADVERTISING 17-109: RESOLUTION RECOGNIZING HEALTHCARE AS A BASIC HUMAN RIGHT 17-208: RESOLUTION REVISING HEALTH CARE LEGISLATION MSV POLICY 435.012 - STATUTE OF LIMITATIONS
REFERRED TO BOARD OF DIRECTORS AS AMENDED 17-110: VIRGINIA MEDICAL STUDENT CLERKSHIP SUPPORT 17-202: MEDICARE AT 55 ACT
10/12/2018 Page 11 17-203: SINGLE PAYER SYSTEM
WITHDRAWN 17-108: RESOLUTION ON MEMBERSHIP IN MSV COMMITTEES
NOT ADOPTED
17-104: RESOLUTION TO ASK THE MEDICAL SOCIETY OF VIRGINIA (MSV) TO STUDY THE CONSTITUTION OF THE STATE OF VIRGINIA AND PRESENT A PLAN FOR THE CREATION OF AN ENTITY WITHIN THE STATE OF VIRGINIA TO BE RESPONSIBLE FOR AND THE CARRY OUT THE DELIVERY OF MEDICAL CARE
10/12/2018 Page 12 17-101: MEDICAL SOCIETY OF VIRGINIA PROPOSED 2018 BUDGET (ADOPTED)
RESOLVED, that the Medical Society of Virginia approve, as presented, the proposed budget for 2017.
17-102: MSV 2017 POLICY COMPENDIUM TEN YEAR REVIEW (ADOPTED AS AMENDED)
RESOLVED, that the Medical Society of Virginia adopt the recommendations in the previously enclosed report with the following amendments.
MSV Policy 435.012, Statute of Limitations, was extracted and referred to the Board of Directors.
435.012 - Statute of Limitations Date: 11/8/1997 The Medical Society of Virginia supports a two-year statute of limitations without a discovery rule for medical malpractice. Reaffirmed 10/28/2007
17-103: MSV POLICY COMPENDIUM UPDATES (ADOPTED)
RESOLVED, that the Medical Society of Virginia adopt the recommendations in the previously enclosed report.
17-104: RESOLUTION TO ASK THE MEDICAL SOCIETY OF VIRGINIA (MSV) TO STUDY THE CONSTITUTION OF THE STATE OF VIRGINIA AND PRESENT A PLAN FOR THE CREATION OF AN ENTITY WITHIN THE STATE OF VIRGINIA TO BE RESPONSIBLE FOR AND THE CARRY OUT THE DELIVERY OF MEDICAL CARE (NOT ADOPTED)
RESOLVED, that the MSV study the composition of the Virginia state Constitution and present a plan for an entity within the state to be responsible for and carry out the delivery of healthcare.
17-105: TRUTH IN ADVERTISING (REFERRED TO THE BOARD OF DIRECTORS)
RESOLVED, the Medical Society of Virginia supports specifying that “board-certified” must refer to an American Board of Medical Specialties (ABMS), American Osteopathic Association Board Certification (AOA), or other boards that maintain similarly high standards of certification.
17-106: RESOLUTION TO IMPROVE OBESITY MEDICARE & INSURANCE COVERAGE (ADOPTED AS AMENDED)
RESOLVED, that the Richmond Academy of Medicine and the Medical Society of Virginia through its delegation to the AMA support coverage for healthcare costs associated with medical, surgical, nutritional and behavioral treatment interventions for patients diagnosed with obesity.
10/12/2018 Page 13 17-107: AMA POTENTIAL RESOLUTION: I-17 FEES FOR TAKING MAINTENANCE OF CERTIFICATION EXAMINATION (ADOPTED AS AMENDED BY SUBSTITUTION)
RESOLVED, the Medical Society of Virginia through its delegation to the American Medical Association support efforts to ensure financial transparency and a fair fee structure in the MOC fee schedule and to support efforts to reduce MOC fees including a reduction in fees for those who complete requirements through alternative but approved pathways.
17-108: RESOLUTION ON MEMBERSHIP IN MSV COMMITTEES (WITHDRAWN)
RESOLVED, that membership on the MSV Advocacy Committee have, in addition to membership in MSV, a requirement of active membership in a recognized component society or a specialist society, and be it further
RESOLVED, that active membership in a component society or a specialist society be strongly encouraged for members being considered for appointment to all MSV committees, taskforces, etc., and be it further
RESOLVED, that preference will be given to candidates who are active members of both a component society and a specialist society.
17-109: RESOLUTION RECOGNIZING HEALTHCARE AS A BASIC HUMAN RIGHT (REFERRED TO THE BOARD OF DIRECTORS)
RESOLVED, that the Medical Society of Virginia join with the many professional societies that recognizes that health care is a basic human right for every person and not a privilege.
17-110: VIRGINIA MEDICAL STUDENT CLERKSHIP SUPPORT (AMENDED AND REFERRED TO BOARD OF DIRECTORS)
RESOLVED, that the Medical Society of Virginia support tax credits for community-based physicians providing uncompensated direct supervision during educational clerkships to medical students, physician assistant students, and nurse practitioner students matriculating in the Commonwealth of Virginia.
17-111: REVISION OF "GOOD SAMARITAN" STATUTES FOR TEAM PHYSICIANS (ADOPTED AS AMENDED)
RESOLVED, the Medical Society of Virginia will supports including in the Code of Virginia liability protection for simple negligence for volunteer physicians providing both emergent and non-emergent health care by volunteer team physicians at athletic events or in athletic programs in the Commonwealth of Virginia.
17-112: HUMAN TRAFFICKING (ADOPTED AS AMENDED)
10/12/2018 Page 14 RESOLVED, that MSV develop a policy to assist physicians in the Commonwealth to identify these individuals victims of human trafficking and provide guidelines that allow physicians to report their concerns to the appropriate governmental agencies with anonymity.
17-201: MEDICAID EXPANSION (REAFFIRMATION OF MSV POLICY 290.008)
290.008 - Expand Medicaid under the ACA Date: 11/2/2012 The Medical Society of Virginia supports legislation to fully expand Medicaid under the limits set by the ACA with two conditions: 1) that any expansion be fiscally responsible; and 2) that such expansion reimburse physicians for provision of professional services to Medicaid patients at a rate that assures access to care for Medicaid patients.
17-202: MEDICARE AT 55 ACT (REFERED TO THE BOARD AS AMENDED)
RESOLVED, that the MSV instruct our AMA Delegation to recommend that the AMA support the “Medicar e at 55 Act ” in trod uced by Sen ator D ebb ie St abenow (D -Mich), allowing Americans aged 55- who are vulnerable to significant illness to buy into Medicare early and obtain better and less expensive health coverage compared to private insurers who could charge them three times or higher.
17-203: SINGLE PAYER SYSTEM (REFERED TO THE BOARD AS AMENDED)
RESOLVED, the MSV amend by substitution policy 165.016 with the following language:
“MSV will support a national system of providing and financing a Single Payer System of health insurance that will: Cover everyone, without copays or deductibles, for all medically necessary care, using a single large and efficient risk pool that does not penalize people based on age, illness, or disability; and where everyone contributes, based on payroll, income, and other progressive taxes; Promote competition and preserve a patient's choice of physician or other health care provider, including hospital and other health care facilities; Relieve businesses of all sizes from providing health insurance to their employees, thus removing the tie between an individual’s health insurance and their employment; and Advance an efficient and provider-friendly administrative and reimbursement system”, and therefore be it further RESOLVED, t he MSV sup ports H.R. 676, the “Expa n ded and Improve d Medic are for All Act ”, w hich propos es cha ng ing our h ea lth insura nce paym ent syst em into an ‘Im proved Med icare for A ll/ S ing le Payer System ’, an d
RESOLVED, the MSV AMA delegation shall bring a resolution stating the same principles, and supporting H.R. 676, to the next annual conference of the American Medical Association for their approval.
17-204: GUN VIOLENCE RESTRAINING ORDERS (ADOPTED)
RESOLVED, that the Medical Society of Virginia support gun violence restraining orders as a
10/12/2018 Page 15 mechanism to decrease gun related suicides and homicides.
REAFFIRM EXISTING POLICIES 145.001, 145.002, AND 145.003
145.001 - Children and Gun Safety Date: 10/30/1999 The Medical Society of Virginia supports legislation to require safety devices to be sold with each gun sold in Virginia, either at a regulated gun store or through other means such as gun shows. Further, the MSV continues to support Medical Society of Virginia Alliance and other public education gun safety programs. Reaffirmed 10/24/2010 Reaffirmed 10/26/2014
145.002 - Control of Violent Use of Firearms Date: 11/11/1989 The Medical Society of Virginia supports methods to control the misuse and violent use of firearms. Reaffirmed 10/25/2009 Reaffirmed 10/26/2014
145.003 - Support for Firearm Laws Promoting Increased Public Safety Date: 11/2/2012 The Medical Society of Virginia opposes repeal of existing state or federal laws and regulations that promote safety and responsibility in the purchase, possession or use of firearms and ammunition. The MSV supports future laws and regulations relating to firearms which would promote trauma control and increased public safety. Reaffirmed 10/26/2014
17-205: MEDICAID REFORM FOR ADULTS RECEIVING SOCIAL SECURITY DISABILITY INCOME (ADOPTED AS AMENDED)
RESOLVED, that the MSV support automatically allowing Virginians on SSDI to meet income eligibility requirements for enrolling patients in Virginia on SSDI onto Medicaid without consideration of their SSDI.
17-206: RESOLUTION ON TOBACCO CONTROL AND HEALTH CARE IN VIRGINIA (ADOPTED AS AMENDED)
RESOLVED, that the Medical Society of Virginia revise current policy 505.003 as follows: (changes underlined)
The Medical Society of Virginia strongly supports a significant tobacco tax equivalent to at least the national average increase of at least $1.35 to reach the national average of $1.65 for this tax as a measure to reduce tobacco use in our population. The Medical Society of Virginia supports legislation which would require that at least 10% of the funds generated by an increase in the state tobacco tax be used to support health related programs for the citizens in of the Commonwealth.
17-207: RESOLUTION TO IMPROVE STEP THERAPY IN VIRGINIA (ADOPTED AS AMENDED)
10/12/2018 Page 16 RESOLVED, that MSV work with stakeholders to reform step therapy in Virginia to require health plans, pharmacy benefit managers (PBMs) and other entities involved to cite clinical review data as justification for denials, create a uniform and expedited appeals and exception process, and establish a process for patients who transition from one insurance plans to another.
17-208: RESOLUTION REVISING HEALTH CARE LEGISLATION (REFERRED TO THE BOARD OF DIRECTORS)
RESOLVED, that it be policy of the MSV to communicate to the public and to our legislators our strong support for the 2017 American Medical Association list of guiding principles for health insurance and health care access for any future federal or Commonwealth government health care plans.
17-209: RESOLUTION TO IMPROVE UPON THE CURRENT PRIOR-AUTHORIZATION LAW IN THE STATE OF VIRGINIA (ADOPTED AS AMENDED)
RESOLVED, that the Medical Society of Virginia advocates for open disclosure of insurer’s approval and rejection processes and be it further,
RESOLVED, that the MSV insists that insurers’ release information identifying the common evidence-based parameters for insurers’ approval of the 10 most frequently prescribed chronic disease management prescription drugs, as required by the 2015 Virginia law and §38.2-34078.15.2, and be it further
RESOLVED, that the Medical Society of Virginia work to require insurance companies, pharmacy benefit managers (PBMs) and other entities involved to upgrade the electronic approval of prescription requests, which has shown to bring cost savings in other states within a few years of its implementation, and be it further
RESOLVED, that the Medical Society of Virginia will join the American Medical Association to aid prior authorization reform with a goal of building a dialogue between providers, health plans, and their third parties to eliminate administrative waste from the system.
17-210: OPPOSING HEALTH PLANS RESTRICTING MEDICALLY NECESSARY CARE (ADOPTED) RESOLVED, the Medical Society of Virginia opposes any health plan mechanism that interferes in the timely delivery of medically necessary care, therefore be it further
RESOLVED, the Medical Society of Virginia supports requiring health plans to provide physicians with real time access to covered benefits, the criteria for “medical necessity” and cost information so that physicians and their patients may work together to choose the most cost-effective medically appropriate treatment for patient care.
17-211: RESOLUTION REGARDING THE WITHDRAWAL OF INSURANCE PROVIDERS FROM THE ACA AND INDIVIDUAL MARKETPLACE (ADOPTED AS AMENDED)
10/12/2018 Page 17 RESOLVED, that the Medical Society of Virginia propose policy changes which will require health plans participating in the Commonwealth of Virginia State Benefits Program to also provide individual coverage for the public at large in the regions in which they participate, and be it further
RESOLVED, these individual policies must be commensurate with what the plans offers to state employees including both benefits, and premiums and administrative expenses.
17-212 E-PRESCRIBING OF SCHEDULE II MEDICATIONS (ADOPTED AS AMENDED)
RESOLVED, that this initiative be undertaken within the next 3 months with a goal to make recommendations that can be shared and receive feedback from MSV members within 6 months, and be it further
RESOLVED, that the task force explore and consider the following topics: • Mandatory e prescribing for schedule 2 medications • Requiring a patient-physician relationship based upon a face to face clinical encounter as defined by the health regulatory board of Virginia (or, in the case of a covering situation, clinic) • All electronic prescribing software approved for use in Virginia be connected to the PMP (all electronic prescribing platforms must be interoperable). • Interoperability with the PMP’s of Virginia’s bordering states. • Waivers and/or subsidization for doctors documenting financial hardship, technology challenges and/or no local broadband service, and for those who write few schedule II prescriptions. • Identifying the costs associated with implementing the process for physicians and physician groups and how to make it affordable. • Guidelines on the use paper of prescriptions for specified situations and settings. • Appropriateness of variable prescribing limits for specific meds and/or dosing based upon patient’s condition, type (hospice), and physician specialty and, possibly, with opioid/pain med CME requirements • Design methods for data collection to monitor impact and other research considerations • Design methods to detect problem patients and physicians and consider methods for prevention and intervention when necessary, and be it further
RESOLVED, that this taskforce shall make a report to the MSV Board of Directors with a recommended position on mandatory e-prescribing to inform the ongoing work as established by HB 2165.
10/12/2018 Page 18 An updated copy of this document will be provided to delegates after the October Board of Directors' 2017-2018 BOARD ACTIONS meeting
RESOLUTION HOD BOARD ACTION FINAL ACTION ACTION 17-105: TRUTH IN ADVERTISING Referred to TBD at the October 18th Board TBD Board of meeting. Rescheduled from RESOLVED, the Medical Society of Virginia supports Directors September meeting due to Hurricane specifying that “board-certified” must refer to an American Florence. Board of Medical Specialties (ABMS), American Osteopathic Association Board Certification (AOA), or other boards that This document will be updated maintain similarly high standards of certification. pending Board decision and made available to delegates. 17-109: RESOLUTION RECOGNIZING HEALTHCARE AS Referred to At the April 28, 2018 meeting, the N/A A BASIC HUMAN RIGHT Board of MSV Board discussed the resolution, Directors corresponding amendments, and RESOLVED, that the Medical Society of Virginia join with the issue. many professional societies that recognizes that health care is a basic human right for every person and not a privilege. Resolution 17-109 was not adopted.
17-110: VIRGINIA MEDICAL STUDENT CLERKSHIP Referred to At the February 7, 2018 and the April The MSV Policy Compendium was SUPPORT Board of 28, 2018 meeting, the MSV Board updated accordingly. Directors discussed the resolution, RESOLVED, that the Medical Society of Virginia support as corresponding amendments, and 20.2.03 Virginia Medical Clerkship tax credits for community-based physicians providing Amended issue. Support uncompensated direct supervision during educational Date: 4/28/2018 clerkships to medical students, physician assistant Resolution 17-110 was adopted as The Medical Society of Virginia supports students, and nurse practitioner students matriculating in amended. tax credits for physicians providing the Commonwealth of Virginia. uncompensated supervised education during health care clerkships to students and residents matriculating in the Commonwealth of Virginia, District of Columbia or surrounding states.
10/12/2018 Page 19 17-202: MEDICARE AT 55 ACT Referred to At the April 28, 2018 meeting, the Board of MSV Board discussed the resolution, N/A RESOLVED, that the MSV instruct our AMA Delegation to Directors corresponding amendments, and recommend that the AMA support the “Medicar e at 55 Act ” in as issue. trod uced by Sen ator D ebb ie St aben ow (D -Mich), allowing Amended Americans aged 55-who are vulnerable to significant illness to Resolution 17-202 was not adopted. buy into Medicare early and obtain better and less expensive health coverage compared to private insurers who could charge them three times or higher.
17-203: SINGLE PAYER SYSTEM Referred to At the April 28, 2018 meeting, the The MSV Policy Compendium was RESOLVED, the MSV amend by substitution policy 165.016 Board of MSV Board discussed the resolution, updated accordingly. with the following language: Directors corresponding amendments, and as issue. 10.3.02- Single Payer System “MSV will support a national system of providing and Amended Date: 10/31/1992 financing a Single Payer System of health insurance that Resolution 17-203 was adopted as The Medical Society of Virginia will will: amended. support discussion of a national system Cover everyone, without copays or deductibles, for all of providing and financing a Single Payer medically necessary care, using a single large and System of health insurance. efficient risk pool that does not penalize people based Reaffirmed 11/2/2012 on age, illness, or disability; and where everyone Reaffirmed as amended 4/28/2018 contributes, based on payroll, income, and other progressive taxes; Promote competition and preserve a patient's choice of physician or other health care provider, including hospital and other health care facilities; Relieve businesses of all sizes from providing health insurance to their employees, thus removing the tie between an individual’s health insurance and their employment; and Advance an efficient and provider-friendly administrative and reimbursement system”, and therefore be it further RESOLVED, t he MSV sup ports H.R. 676, the “Expa n ded and Improve d Med icare for All Act ”, w hich proposes cha ng ing our h ea lth insura nce paym ent syst em into an ‘Im proved Med icare for A ll/ S ing le Payer System ’, an d
RESOLVED, the MSV AMA delegation shall bring a resolution stating the same principles, and supporting H.R. 676, to the next annual conference of the American Medical Association for their approval.
10/12/2018 Page 20 17-208: RESOLUTION REVISING HEALTH CARE Referred to TBD at the October 18th Board TBD LEGISLATION Board of meeting. Rescheduled from RESOLVED, that it be policy of the MSV to Directors September meeting due to communicate to the public and to our legislators Hurricane Florence. our strong support for the 2017 American Medical Association list of guiding principles for health This document will be updated insurance and health care access for any future pending Board decision and federal or Commonwealth government health made available to delegates. care plans.
MSV POLICY 435.012 - STATUTE OF Referred to The Policy Compendium was updated accordingly. LIMITATIONS Board of At the April 28, 2018 meeting, Directors the MSV Board discussed the 15.3.06- Statute of Limitations 435.012 - Statute of Limitations policy and consulted with Date: 11/8/1997 Date: 11/8/1997 General Counsel regarding Virginia statute of limitations. ADULT PATIENTS – The Medical Society of Virginia The Medical Society of Virginia supports a two-year supports a two year statute of limitation from the date statute of limitations without a discovery rule for The policy was reaffirmed as of injury and in cases of retained foreign bodies, medical malpractice. amended. fraud, or failure to diagnose cancer; one year from Reaffirmed 10/28/2007 the date of discovery.
MINOR PATIENTS – The Medical Society of Virginia supports the longer statute of limitations for minors as currently set forth in Virginia law. Reaffirmed 10/28/2007 Reaffirmed as amended 4/28/2018
10/12/2018 Page 21 Date: September 2018 To: MSV Membership From: MSV Nominating Committee Re: Nominating Committee Report for 2018 Annual Meeting
The Nominating Committee has met and proposes the following slate for the 2018-2019 year:
OFFICERS President-Elect Clifford L Deal, M.D. Secretary-Treasurer Larry G. Mitchell, M.D. Speaker Arthur J. Vayer Jr., M.D. Vice Speaker Alan H. Wynn, M.D.
DIRECTORS (Elected for 2-year term) District 2 Joel T. Bundy, M.D. District 2 Edilberto O. Pelausa, M.D. District 6 Trevar O. Chapmon, M.D. District 8 Atul V. Marathe, M.D. District 10 Andrea R. Giacometti, M.D. District 10 William E. Prominski, M.D. Academic Karen S. Rheuban, M.D.
DIRECTORS (Elected for 1-year term) Resident Lee Ouyang, M.D. Medical Student Meredith P. Johnson
ASSOCIATE DIRECTORS (Elected for 2-year term) District 2 Lisa S. Kennedy, M.D. District 6 Mark D. Townsend, M.D. District 8 Marc C. Alembik, M.D. District 10 Tarek Abou-Ghazala, M.D. Academic Alice T. Coombs, M.D.
ASSOCIATE DIRECTORS (Elected for 1-year term) District 3 Harry J. Shaia, M.D Resident Kenneth D. Qiu, M.D Medical Student Michael R. Pierce
AMA DELEGATES (Elected for 2-year calendar terms) Thomas W. Eppes Jr., M.D. Lawrence K. Monahan, M.D. William C. Reha, M.D., M.B.A.
AMA ALTERNATE DELEGATES (Elected for 2-year calendar terms) Edward G. Koch, M.D. Michele A. Nedelka, M.D. Sterling N. Ransone Jr., M.D. Cynthia C. Romero, M.D.
10/12/2018 Page 22 18-101
Medical Society of Virginia Proposed 2019 Budget
Submitted by: the MSV Board of Directors
To ensure that the proposed budget is consistent with evolving financial conditions, the MSV Board of Directors will review and approve an updated budget at its October meeting immediately preceding the House of Delegates; the approved budget will then be distributed to the House of Delegates at its first session.
10/12/2018 Page 23
18-102
MSV 2018 POLICY COMPENDIUM TEN YEAR REVIEW
Submitted by: Dr. Arthur Vayer Jr., Speaker and Dr. Alan Wynn, Vice-Speaker
WHEREAS, the policy making procedure for implementation and utilization of the Policy Compendium of the Medical Society of Virginia was adopted by the Board in September 1992, and updated in 2001, and
WHEREAS, the procedure requires that 10 years after the adoption of each policy action, the Speakers and MSV Staff will present to the House of Delegates a “Ten Year Policy Review Report,” encouraging appropriate consideration of each item, and that unless each such policy is acted upon by the subsequent House of Delegates, it will cease to be policy to the MSV and will be placed in the archives section of the Compendium, and
WHEREAS, consideration by the House of Delegates to add, amend or archive additional policies prior to ten years after their adoption may be included in the review as deemed appropriate by the Speakers and MSV Staff, and
WHEREAS, upon review, it is evident that some items in the Policy Compendium should be removed or revised based on their relevance or timeliness, therefore be it
RESOLVED, that the Medical Society of Virginia adopt the recommendations in the enclosed report.
10/12/2018 Page 24
RECOMMENDATION: REAFFIRM
05.4.03 - Continuity of Care
Date: 10/31/1998
The Medical Society of Virginia believes that Virginia physicians performing surgery have an ethical responsibility to continue the care of their individual patients through the post-surgical recovery and healing period.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
10.6.05- Funding for Medicaid
Date: 10/31/1998
The Medical Society of Virginia supports full state and federal funding of the Medicaid program and its potential for improving the health of Virginia’s most vulnerable populations.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
10.7.07- Medicare Fees
Date: 10/31/1998
The Medical Society of Virginia opposes Medicare registration fees, charges for sending paper claims, and levies imposed on physicians whose practice is audited.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
10.7.08- Medicare Reimbursement for Medication
Date: 10/31/1998
The Medical Society of Virginia opposes inadequate Medicare reimbursement for physician purchased medications.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
10.7.09- Medicare Surety Bonds
Date: 10/31/1998
The Medical Society of Virginia opposes the implementation of any requirement by the Centers for Medicare and Medicaid Services that would require physicians to purchase surety bonds.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
10.9.01- Equal Reimbursement for Urban and Rural Areas
Date: 11/9/1991
10/12/2018 Page 25 The Medical Society of Virginia advocates equal reimbursement for health care services in rural and urban areas with support for more rapid recovery of costs for equipment and technology in rural areas where volume use is not as great.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
10.9.11- Most Favored Nation Clauses
Date: 10/31/1998
The Medical Society of Virginia opposes the inclusion in physician insurance contracts of "Most Favored Nation Clauses" which obligate physicians to accept from one insurance company the lowest reimbursement rates that have been negotiated with other insurance companies. MSV supports passage of legislation within the state of Virginia to prohibit this practice.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
10.9.12- Worker’s Compensation Reimbursement
Date: 10/31/1998
The Medical Society of Virginia supports legislation to require third party administrators handling worker's compensation to reimburse physicians within 60 days of submitting a claim; to state that legal action on the part of the patient or employer shall have no effect on provider payment; and to abolish deductions from physician reimbursement to pay for attorney fees in covering patient injuries sustained during employment and possibly covered by workers compensation.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
30.1.02 – Workers’ Compensation: Collection of Attorneys’ Fees
Date: 10/30/1993
The Medical Society of Virginia supports changes in Virginia's Workers' Compensation Statute Section 65.2- 714 to ensure that physicians receive all compensation due them for services rendered.
The Medical Society of Virginia supports changes in Virginia's Workers' Compensation Statute so that any fee to attorneys retained by the employee be paid by either the employee, and in the case the appeal is unsuccessful by the employer, or by the state Workers' Compensation Fund.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
30.3.05- Release Form Information
Date: 10/31/1998
The Medical Society of Virginia recommends that medical records release forms should include the patient’s name, address, date of birth, phone numbers, and a statement that there may be a charge from the sending physician for reproduction and mailing of the chart.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
30.7.05 – Electronic Prescribing
10/12/2018 Page 26 Date: 10/12/2008
The Medical Society of Virginia supports the concept of electronic prescribing, but strongly condemns a funding structure that financially penalizes physicians for not utilizing such technology.
Recommendation: Reaffirm
35.3.04- Listing of Generic and Proprietary Medications when substituted
Date: 10/31/1998
The Medical Society of Virginia supports Code of Virginia § 54.1-3408.03, which requires that pharmacies and other entities which dispense medications to patients list both the generic and the proprietary name for the medication when generic substitution occurs in the Commonwealth of Virginia.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
40.1.12 - Improve Access to Prescription Drugs for the Uninsured
Date: 11/8/1997
MSV requests the AMA to meet with the Pharmaceutical Research and Manufacturers of America to design a universal form for physicians to fill out requesting stock bottles of medications from American pharmaceutical companies for indigent patients.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
40.5.03- Physician Reporting of Cancer Cases
Date: 10/31/1998
MSV strongly believes that all physicians in Virginia should report cases of cancer to the Virginia Cancer Registry unless they can determine that these cases have already been reported by a hospital, clinic, or in- state pathology laboratory.
The Medical Society of Virginia strongly supports the continued collection of basic data on all cancer patients in Virginia by the Department of Health as specifically outlined in Virginia Codes 32.1-70 and 32.1-71B.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
40.6.05- Inclusion of Pediatricians in Development of Family Service Plans
Date: 10/31/1998
The Medical Society of Virginia recommends that Early Childhood Intervention Agencies and Health Insurers in the Commonwealth of Virginia promote voluntary inclusion of pediatric trained physicians in the development of the Individualized Family Service Plans, as required by the Individuals with Disabilities Education Act (IDEA), so that medically-necessary and medically-appropriate services are provided to the child and family.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
40.8.02/440.029 - Uranium Mining in Virginia
10/12/2018 Page 27
Date: 10/12/2008
The Medical Society of Virginia supports continuing the moratorium on uranium mining in Virginia until there is satisfactory evidence that it will not constitute a public health hazard.
Recommendation: Reaffirm
40.21.04- Alcohol/Drug Impaired Drivers
Date: 11/8/1997
The Medical Society of Virginia urges the continued enforcement of administrative driver’s license revocation for drivers whose blood alcohol content exceeds the legal limit or who refuse a blood alcohol determination. The Medical Society of Virginia supports legislation facilitating the prosecution and removal of alcohol and/or drug impaired drivers from the roadways of the Commonwealth.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
45.7.03 - Coverage Limitations on Physician Scope of Practice
Date: 10/31/1998
The Medical Society of Virginia opposes insurance carriers’ coverage determinations which serve to limit the scope of a physicians practice.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
50.1.02- Physician-specific information
Date: 10/31/1998
The Medical Society of Virginia will work with the Board of Medicine to ensure that only appropriate, accurate and necessary physician-specific information, that achieves reasonable and economical disclosure, is available to the public.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
55.1.05- Communications with Local Medical Societies
Date: 10/31/1998
Each local medical society executive director or secretary, or in cases where there is no staff, society presidents or secretaries, will be listed on the MSV membership roster for purposes of receiving all mailings that go to MSV physician members.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
55.1.05- MSV-Local Society Collaboration
Date: 10/31/1998
The Medical Society of Virginia staff will contact and work collaboratively with local societies on issues (especially those relating to managed care and insurance company policies) affecting their particular part of the state.
10/12/2018 Page 28
Reaffirmed 10/12/2008 Recommendation: Reaffirm
55.1.07- Specialty Society inclusion in Legislative Policy
Date: 10/31/1998
The Medical Society of Virginia will request inclusion of representatives of the affiliated specialty societies in the MSV's decision process for legislative action whenever the specialty society or its constituency has a public and vested interest in proposed legislation in the General Assembly of the Commonwealth of Virginia.
Reaffirmed 10/12/2008 Recommendation: Reaffirm
55.2.06- Academic Membership Agreement
Date: 10/31/1998
The Medical Society may offer, with the approval of the Board of Directors, a special dues program with Virginia’s academic medical centers for physicians in a full time academic setting.
Reaffirmed: 10/12/2008 Recommendation: Reaffirm
10/12/2018 Page 29 RECOMMENDATION: REAFFIRM AS AMENDED
10.1.10- Coverage for Newborn Hearing Screenings
Date: 10/31/1998
The Medical Society of Virginia supports mandatory hearing screenings for all newborns and mandatory reimbursement for newborn hearing screenings and follow up diagnostic testing for those infants referred after the initial screening.
Reaffirmed 10/12/2008 Recommendation: Reaffirm as amended
30.1.04 - Coding/Reimbursement for Mental Health Services
Date: 10/31/1998
The Medical Society of Virginia endorses the DSM-IV-PC DSM 5 as the instrument to document and code biopsychosocial data for data collection and for third party payer reimbursement of primary care providers in the Commonwealth of Virginia.
Reaffirmed 10/12/2008 Recommendation: Reaffirm as amended
40.11.03- Hot Boxing Dangerous Rapid Weight Reduction
Date: 10/31/1998
The Medical Society of Virginia opposes the practice of "hot boxing" or any similar any process of dangerous, rapid weight reduction.
Reaffirmed 10/12/2008 Recommendation: Reaffirm as amended
40.6.04- Prevent Blindness Virginia/Conexus
Date: 10/31/1998
The Medical Society of Virginia acknowledges and endorses Prevent Blindness Virginia’s Conexus’s efforts to develop broad-based support from those agencies involved in children’s health and development programs and supports the adoption of statewide screening of Virginia public school children using the Prevent Blindness Virginia’s Conexus’s standardized screening protocol.
Reaffirmed 10/12/2008 Recommendation: Reaffirm as amended
45.1.04- Supervision of Physical Therapy Assistants
Date: 10/31/1998
The Medical Society of Virginia supports legislation to amend the current statute which would permit physicians to supervise supervision of licensed physical therapy assistants.
Reaffirmed 10/12/2008 Recommendation: Reaffirm as amended
10/12/2018 Page 30
RECOMMENDATION: ARCHIVE
40.14.02- Mandatory Newborn Hearing Screening
Date: 11/4/2000
The Medical Society of Virginia supports mandatory hearing screenings for all newborns.
Reaffirmed 10/12/2008 Recommendation: Archive
20.4.03- The Hippocratic Oath
Date: 10/31/1998
The Medical Society of Virginia reaffirms the importance of the Hippocratic Oath and asks that it be taken orally by every medical school graduate at his/her graduation ceremony in the state of Virginia.
Reaffirmed 10/12/2008 Recommendation: Archive
10/12/2018 Page 31 18-103
Updating MSV Bylaws to Increase Physician Participation
Submitted by the MSV Board of Directors
WHEREAS, the Medical Society of Virginia is a membership organization and should encourage physician participation in all MSV activities, and
WHEREAS, under the MSV Bylaws Associate Members have no right to vote, hold office, or serve on committees, and
WHEREAS, physicians serving as a medical officer of the armed forces, a member of the Public Health Service, or attached to a veterans’ hospital are dedicated public servants who bring a valuable perspective to the entire house of medicine and the Medical Society of Virginia, and
WHEREAS, currently physicians serving as a medical officer of the armed forces, a member of the Public Health Service, or attached to a veterans’ hospital are classified as Associate Members under the MSV Bylaws with no right to vote or hold office, and
WHEREAS, a bylaws Committee was appointed by MSV President Dr. Kurtis Elward, comprised of Dr. Richard Szucs as Chair, with Dr. Michael Amster, Dr. Larry Monahan, Dr. Bhushan Pandya, Dr. William Reha, and Dr. Arthur Vayer serving on the Committee, and
WHEREAS, the dues amount for these physician members will not be affected, and
WHEREAS, following the bylaws Committee report, the MSV Board of Directors on this voted to recommend this bylaw change advance to the 2018 HOD, therefore be it
RESOLVED, the Medical Society of Virginia shall amend its bylaws as specified in the provided draft to classify these physicians as public service active members of the medical society.
10/12/2018 Page 32 1 ARTICLE II 2 MEMBERSHIP, VOTING, FUNDS, DUES
3 Section 1. Classes of Membership. The Society shall have the following classes of membership: (a) 4 active, (b) public service active (bc) resident physician, (cd) student, (de) associate, (ef) honorary active, 5 (fg) honorary associate, and (gh) affiliate. 6
7 Section 2. Active Members. An active member must be a doctor of medicine or osteopathy licensed 8 to practice that profession in Virginia, provided, however, that a doctor of medicine or osteopathy may 9 hold active membership without an active Virginia license if fully retired from practice.
10 Any active member shall have the right to vote, service on the Board of Directors, hold any office 11 in the Society and serve on any committee. Each active or associate member shall pay dues unless (i) 12 he/she has been granted an exemption because of financial or physical disability, or (ii) he/she has been 13 an active or associate member of the Society for at least ten years and has become fully retired, in which 14 event he/she shall be granted lifetime membership effective on January 1 of the year immediately 15 following the year of application. Physicians granted such lifetime membership status shall not be 16 charged annual dues. 17
18 Section 3. Public Service Active Members. A public service active member must be (1) a medical 19 officer of the armed forces; (2) a member of the Public Health Service; or (3) a doctor of medicine or 20 osteopathy attached to a veterans’ hospital.
21 Any public service active member shall have the right to vote, service on the Board of Directors, 22 hold any office in the Society and serve on any committee. Each public service active member shall pay 23 dues unless (i) he/she has been granted an exemption because of financial or physical disability, or (ii) 24 he/she has been an active or associate member of the Society for at least ten years and has become fully 25 retired, in which event he/she shall be granted lifetime membership effective on January 1 of the year 26 immediately following the year of application. Physicians granted such lifetime membership status shall 27 not be charged annual dues. 28
29 Section 34. Resident Physician Members. A resident physician member must be an intern, resident 30 or fellow in an approved training program in Virginia. Any resident physician member may hold any office 31 and serve on any committee of the Society. 32
33 Section 45. Student Members. A student member must be a member in good standing of a 34 component student society (as defined in Article III below). Any student membership shall terminate 35 automatically when the member graduates from medical school or when he/she no longer is enrolled in a 36 medical school at which there is a component student society. Any student member may hold any office 37 and serve on any committee of the Society. 38
39 Section 56. Associate Members. An Associate member must be: (1) a non-resident of Virginia, not 40 currently practicing medicine in Virginia and who holds or has held an active license as a physician by the 41 Virginia Board of Medicine; (2) a medical officer of the armed forces; (3) a member of the Public Health 42 Service; or (4) a doctor of medicine or osteopathy attached to a veterans’ hospital. Associate members,
10/12/2018 Page 33 43 other than honorary associate members, shall pay dues unless at the time of payment they have been 44 active members in good standing for more than ten (10) years and are retired.
45 Section 56.1. No Right to Vote. Associate members shall have no right to vote, hold office or 46 serve on committees, but shall be entitled to all other privileges of membership.
10/12/2018 Page 34 18-104
Modernizing the Title of Executive Vice President
Submitted by the MSV Board of Directors
WHEREAS, the Medical Society of Virginia is a physician led- membership organization, and
WHEREAS, the Executive Vice President is appointed by the MSV Board of Directors,
WHEREAS, the MSV bylaws state the Executive Vice President shall function as the Chief of the Society’s staff, and
WHEREAS, a change in title does not impact or change the current job description or compensation for the Executive Vice President, and
WHEREAS, the MSV Board of Directors requested a formal review of the title of the Executive Vice President position by the MSV Compensation Committee,
WHEREAS, the MSV Compensation Committee was presented with information from Glenn Tecker, an expert on association leadership strategy regarding Executive Vice President and Chief Executive Officer titles, and
WHEREAS, the MSV Compensation Committee was presented with a summary of the American Association of Medical Society Executives (AAMSE) Executive Compensation Report which reported top staff employee titles for 20 Medical Societies/Associations, and
WHEREAS, the MSV Compensation Committee recommends updating the title to Executive Vice President and Chief Executive Officer, and
WHEREAS, the MSV Bylaws Committee recommends updating the title to Executive Vice President and Chief Executive Officer, and
WHEREAS, following the Bylaws Committee report, the MSV Board of Directors on this voted to recommend this bylaw change advance to the 2018 HOD, therefore be it
RESOLVED, under the direction of the Speakers, MSV staff and General Counsel shall replace references within MSV Bylaws to “Executive Vice President” with “Executive Vice President and Chief Executive Officer.”
10/12/2018 Page 35 18-105
Clarification of Leadership Conduct Policies and Procedures
Submitted by the MSV Board of Directors
WHEREAS, members of the Medical Society of Virginia Board of Directors will uphold the duties and responsibilities outlined in the MSV Board of Directors Handbook and its appendices, and
WHEREAS, the 2016 House of Delegates reaffirmed policies 55.2.08- Statement of Individual Board Member’s Responsibility and 55.2.09- Statement of Responsibilities of the Board of Directors as a Whole, and
WHEREAS, the Bylaws Committee reviewed the MSV bylaws, which do not contain a reference to the location of those materials, and
WHEREAS, the MSV Bylaws on Professional Conduct, requires the utmost clarity, and
WHEREAS, following the bylaws Committee report, the MSV Board of Directors on this voted to recommend this bylaw change advance to the 2018 HOD, therefore be it
RESOLVED, the Medical Society of Virginia shall amend its bylaws as specified in the provided draft.
10/12/2018 Page 36 1 ARTICLE IX 2 PROFESSIONAL CONDUCT 3 4 Section 1. Professional Conduct. Each officer, Associate Director, or Director of the Society shall 5 conduct themselves in a professional and ethical manner in discharging the duties of the respective 6 office, while taking appropriate action to advance and foster the business of the Society. Each officer or 7 director of the Society will remain in compliance with these bylaws and with the Society’s Code of 8 Conduct contained within the Society’s Board of Directors Handbookand these bylaws. 9 10 Each officer, Associate Director, or Director of the Society will utilize the Society’s Conflict Resolution 11 Processes, contained within the Society’s Board of Directors Handbook, as the primary mechanism to 12 resolve conflict and/or complaints, unless the act or conduct is consistent with Article IX Section 2. 13 14 15 Section 2. Removal Process and Proceedings 16 17 Any officer, Associate Director, Director may be removed from office for cause. Grounds for removal 18 include but are not limited to any of the following circumstances: 19 20 1. Continued, gross, or willful neglect of the duties of the office, which in part include duties of 21 care, loyalty, and diligence, in addition to fiduciary duty 22 2. Actions that intentionally violate the bylaws 23 3. Failure to comply with the proper direction given by the Board 24 4. Failure or refusal to disclose necessary information on matters of organization business 25 5. Unauthorized expenditures or misuse of organization funds 26 6. Unwarranted attacks on any officer, member of the board of directors, board as a whole, or 27 staff, on an ongoing basis 28 7. Misrepresentation of the organization and its officers to outside persons 29 8. Conviction for a felony 30 9. Failure to adhere to professional ethics or any other action(s) deemed injurious to the 31 reputation of, or inconsistent with the best interests of the Society 32 33 Proceedings for the removal from office of an officer other than the Executive Vice 34 President, an Associate Director, or a Director of this Society from office shall be commenced by the filing 35 to the Executive Vice President a written complaint signed by not less than one-third of the Board of 36 Directors. Proceedings for the removal of the Executive Vice President of this Society shall be 37 commenced by the filing with the General Counsel and President a written complaint signed by not less 38 than one-third of the Board of Directors. Such complaint shall name the person sought to be removed, 39 shall state the cause for removal, and shall demand that a meeting of the Board of Directors be held for 40 the purpose of conducting a hearing on the charges set forth in the complaint. 41 42 At the hearing upon such charges the person named in the complaint shall be afforded full opportunity to 43 be heard in his/her own defense, to be represented by legal counsel at personal expense or any other 44 person of his/her own choosing, to cross-examine the witnesses who testify against him/her, and to 45 examine witnesses and offer evidence in his/her own behalf. The Board of Directors shall convene for the 46 purposes of hearing the charges in such complaint no less than sixty (60) days subsequent to the date of 47 the service of the written notice upon such person sought to be removed. 48 49 A quorum for the purposes of this section shall consist of two-thirds (2/3) of the members of the Board of 50 Directors. Removal shall occur by a vote of two-thirds of the Board of Directors present at such meeting. 51 52 The hearing rights under these bylaws do not apply if an individual voluntarily resigns in accordance with 53 these Bylaws.
10/12/2018 Page 37 18-106 Physician and Medical Staff Bill of Rights
Submitted by: Virginia Delegation to the AMA
WHEREAS, current MSV policy does not contain language protecting and directing members on their rights and responsibilities of holding hospital privileges, and
WHEREAS, the enclosed AMA has relevant policy H-225,942 “Physician and Medical Staff Bill of Rights” amended at the Annual 2018 American Medical Association House of Delegate meeting that could serve as a template for MSV, and
WHEREAS, instances have arisen in the Commonwealth where the Board of Directors of a hospital or hospital system have ignored or usurped the medical staff Bylaws for their own benefit, therefore be it
RESOLVED, that our Medical Society of Virginia adopt AMA policy H-225,942 “Physician and Medical Staff Bill of Rights” in the MSV Policy Compendium.
10/12/2018 Page 38 American Medical Association Policy H-225.942 - Physician and Medical Staff Member Bill of Rights
Our AMA adopts and will distribute the following Medical Staff Rights and Responsibilities:
Preamble
The organized medical staff, hospital governing body and administration are all integral to the provision of quality care, providing a safe environment for patients, staff and visitors, and working continuously to improve patient care and outcomes. They operate in distinct, highly expert fields to fulfill common goals, and are each responsible for carrying out primary responsibilities that cannot be delegated.
The organized medical staff consists of practicing physicians who not only have medical expertise but also possess a specialized knowledge that can be acquired only through daily experiences at the frontline of patient care. These personal interactions between medical staff physicians and their patients lead to an accountability distinct from that of other stakeholders in the hospital. This accountability requires that physicians remain answerable first and foremost to their patients.
Medical staff self-governance is vital in protecting the ability of physicians to act in their patients best interest. Only within the confines of the principles and processes of self-governance can physicians ultimately ensure that all treatment decisions remain insulated from interference motivated by commercial or other interests that may threaten high-quality patient care.
From this fundamental understanding flow the following Medical Staff Rights and Responsibilities:
I. Our AMA recognizes the following fundamental responsibilities of the medical staff: a. The responsibility to provide for the delivery of high-quality and safe patient care, the provision of which relies on mutual accountability and interdependence with the health care organizations governing body. b. The responsibility to provide leadership and work collaboratively with the health care organizations administration and governing body to continuously improve patient care and outcomes. c. The responsibility to participate in the health care organization's operational and strategic planning to safeguard the interest of patients, the community, the health care organization, and the medical staff and its members. d. The responsibility to establish qualifications for membership and fairly evaluate all members and candidates without the use of economic criteria unrelated to quality, and to identify and manage potential conflicts that could result in unfair evaluation. e. The responsibility to establish standards and hold members individually and collectively accountable for quality, safety, and professional conduct. f. The responsibility to make appropriate recommendations to the health care organization's governing body regarding membership, privileging, patient care, and peer review.
II. Our AMA recognizes that the following fundamental rights of the medical staff are essential to the medical staffs ability to fulfill its responsibilities: a. The right to be self-governed, which includes but is not limited to (i) initiating, developing, and approving or disapproving of medical staff bylaws, rules and regulations, (ii) selecting and removing medical staff leaders, (iii) controlling the use of medical staff funds, (iv) being advised by independent legal counsel, and (v) establishing and defining, in accordance with applicable law, medical staff membership categories, including categories for non-physician members. b. The right to advocate for its members and their patients without fear of retaliation by the health care organizations administration or governing body. c. The right to be provided with the resources necessary to continuously improve patient care and outcomes. d. The right to be well informed and share in the decision-making of the health care organization's
10/12/2018 Page 39 operational and strategic planning, including involvement in decisions to grant exclusive contracts or close medical staff departments. e. The right to be represented and heard, with or without vote, at all meetings of the health care organizations governing body. f. The right to engage the health care organizations administration and governing body on professional matters involving their own interests.
III. Our AMA recognizes the following fundamental responsibilities of individual medical staff members, regardless of employment or contractual status: a. The responsibility to work collaboratively with other members and with the health care organizations administration to improve quality and safety. b. The responsibility to provide patient care that meets the professional standards established by the medical staff. c. The responsibility to conduct all professional activities in accordance with the bylaws, rules, and regulations of the medical staff. d. The responsibility to advocate for the best interest of patients, even when such interest may conflict with the interests of other members, the medical staff, or the health care organization. e. The responsibility to participate and encourage others to play an active role in the governance and other activities of the medical staff. f. The responsibility to participate in peer review activities, including submitting to review, contributing as a reviewer, and supporting member improvement.
IV. Our AMA recognizes that the following fundamental rights apply to individual medical staff members, regardless of employment, contractual, or independent status, and are essential to each members ability to fulfill the responsibilities owed to his or her patients, the medical staff, and the health care organization: a. The right to exercise fully the prerogatives of medical staff membership afforded by the medical staff bylaws. b. The right to make treatment decisions, including referrals, based on the best interest of the patient, subject to review only by peers. c. The right to exercise personal and professional judgment in voting, speaking, and advocating on any matter regarding patient care or medical staff matters, without fear of retaliation by the medical staff or the health care organizations administration or governing body. d. The right to be evaluated fairly, without the use of economic criteria, by unbiased peers who are actively practicing physicians in the community and in the same specialty. e. The right to full due process before the medical staff or health care organization takes adverse action affecting membership or privileges, including any attempt to abridge membership or privileges through the granting of exclusive contracts or closing of medical staff departments. f. The right to immunity from civil damages, injunctive or equitable relief, criminal liability, and protection from any retaliatory actions, when participating in good faith peer review activities.
Policy Timeline
BOT Rep. 09, A-17 Modified: BOT Rep. 05, I-17 Appended: Res. 715, A-18
10/12/2018 Page 40 Staff Analysis – Resolution 18-106: Physician and Medical Staff Bill of Rights Submitted by Virginia Delegation to the AMA
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
Empower 05.3.01- Physician Benefits: Staff recommends this resolution be The AMA has adopted a policy physicians to Members adopted. that recognizes the following manage Date: 11/5/1994 Would provide all fundamental responsibilities of change The Medical Society of physicians with a the medical staff Virginia believes that baseline level of rights This resolution builds upon existing physicians should serve on and responsibilities when MSV policy 05.3.01 and provides a The policy includes protecting the hospital governing boards providing patient care in a detailed foundation for physicians to rights and responsibilities of all and action committees hospital/health system work cooperatively with medical staff members, Reaffirmed 11/7/2004 setting. hospitals/health systems to ensure regardless of employment, Reaffirmed 10/26/2014 high quality patient care. contractual, or independent Articulates the status. physician’s rights, but also responsibilities. These rights and responsibilities address the individual physician, Focus is on ensuring their patients, the medical staff, physicians can deliver and the health care organization patient-centered care.
The resolution asks MSV to adopt the enclosed AMA policy Drawbacks: into the MSV policy compendium. None.
10/12/2018 Page 41 18-107
Rescind Policy 45.1.07
Submitted by: Hugh Bryan, MD
WHEREAS, Policy 45.1.07 (Scope of Practice Position Statement) was adopted as policy by the House of Delegates in 2001, reaffirmed in 2001 and amended/reaffirmed in 2017, and
WHEREAS, the Executive Committee and the Board of Directors had to violate this policy during negotiations with nurse practitioners in order to support HB793 as amended, and
WHEREAS, HB 793 allows independent practice of nurse practitioners outside of a physician led patient care team, and
WHEREAS, it is likely that the Board of Directors will face similar situations with other mid-level provider groups, and
WHEREAS, the House of Delegates remains defined in the bylaws as the “policy making body of the Society”, and
WHEREAS, the Board of Directors requires flexibility in dealing with these complex issues AND it should avoid violating MSV policy, therefore be it
RESOLVED, that the House of Delegates rescind policy 45.1.07.
10/12/2018 Page 42 Staff Analysis – Resolution 18-107: Rescind Policy 45.1.07
Submitted by Hugh Bryan, M.D.
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
During the 2018 General Assembly Raise perceived 45.1.07 - (See next page) Benefits: Staff recommends this resolution session a bill was introduced to grant value of be not adopted. independent practice to Nurse physicians Removing the policy Practitioners after only 6 months in would eliminate any Policies within the MSV Policy practice with either an NP or a physician. conflict between Virginia Compendium provide guidance on law and MSV’s position numerous and complex issues. MSV opposed this bill and worked on scope of practice. While the ultimate goal is to have diligently to try to kill the bill. Virginia law align with MSV policy when that is not possible, it is Unfortunately, MSV was told a bill must Drawbacks: helpful to maintain what the ideal move forward and so MSV, along with MSV position is within the Policy Virginia specialty societies, worked to Rescinding the policy Compendium to ensure the create a strong alternative option. would mean that MSV organization has a baseline for no longer would have a which to take action. The revised bill was carried by Del. Scott position on scope of Garret MD and included: practice matters to guide If the House were to adopt this MSV action. resolution, additional policies 5 years of practice experience with a would likely need to be rescinded physician of the same as there are many aspirational specialty/same patient population; policies that currently also conflict Only a patient care team physician with Virginia law. can sign attestation if practice in same specialty and filed with Joint Boards; Requires practice after transition to be in the same field of licensure; Requires NP to have a plan to refer complex cases, consult other health care providers and refer emergencies
This resolution asks to rescind MSV’s policy on scope of practice (45.1.07)
10/12/2018 Page 43 45.1.07- Scope of Practice Position Statement Date: 1/9/2001
The Medical Society of Virginia believes a patient care team offers the highest quality of care to patients in the Commonwealth. To ensure quality of care, maximize continuity and coordination of care and to guarantee patients are diagnosed by or directed to the most appropriate provider of care, independent practice by allied health or mid-level health practitioners would fragment care and must be opposed.
Experience and the literature are clear that the best quality health care is delivered by health care teams that collaborate closely and share responsibilities according to their unique abilities and training. These teams are best led by physicians whose intensive and extensive education and ongoing rigorous regulation qualify them to oversee the many variables inherent in patient care.
A collaborative practice is one where the health care providers work together in complimentary interdependent roles to provide the highest quality care for patients, families, and communities.
Physicians should work closely with many mid-level providers and it is necessary that they should develop guidelines for these types of relationships. This is especially important to ensure that each patient is seeing the most appropriate health care provider for their needs and that care can be coordinated effectively and delivered safely.
Therefore, the Medical Society of Virginia accepts the following position statements on Guidelines for Physicians supervising mid-level and allied health providers:
1. The physician is ultimately responsible for coordinating and managing the care of patients, and with the appropriate input of other health providers, ensuring the quality of health care provided to patients in all settings.
2. Health care services delivered by physicians and mid-level or allied health providers must be within the boundaries of each practitioner's authorized scope of practice, as defined by state law. 3. The role of the mid-level and allied health providers in the delivery of care should be defined through mutually agreed upon collaborative guidelines, protocols and agreements that reflect the best available information for delivery of care. 4. The extent of involvement by mid-level and allied health providers in the assessment and implementation of treatment will depend on the complexity and acuity of the patient's condition and the training, experience and preparation of the provider as adjudged by the physician and as outlined in the collaborative agreement. 5. The physician will strive to set the highest standards for the supervision of mid-level and allied health providers in all settings. The physician, when appropriate and in collaboration with allied health providers, should also delineate when collaboration is appropriate. Physicians should not supervise providers with whose abilities they are not familiar. 6. The physician must be available for consultation with mid-level or allied health providers at all times, either in person or through telecommunication systems or reasonably available means. 7. Patients should be made clearly aware at all times whether they are being cared for by a physician or a mid-level or allied health provider 8. The physician and mid-level or allied health provider together should review all delegated patient services on a regular basis, as well as the mutually agreed upon protocols or guidelines for practice. 9. The physician is responsible for clarifying and familiarizing the mid-level or allied health provider with his/her supervising methods and means of delegating patient care. 10. The patient care team should determine how to accept reimbursement for patient care; such methods should support the collaborative work by the patient care team. 11. The Department of Health Professions and the Board of Medicine are the appropriate governmental bodies to be charged with carefully studying and making recommendations regarding issues of licensure.
The Medical Society of Virginia will work collaboratively with physician specialty societies on scope of practice matters to achieve the best outcomes for patients in the Commonwealth.
Reaffirmed 10/28/2007 Reaffirmed as amended 10/22/2017
10/12/2018 Page 44 18-108
Establish Evidence-Based Guidelines for MSV Resolutions
Submitted by: MSV Medical Student Section
WHEREAS, resolutions are fundamental mechanisms in policy making for the Medical Society of Virginia, and
WHEREAS, resolutions allow MSV members to convert ideas into policy, and
WHEREAS, “whereas” clauses are essential components of resolutions providing educational background and information regarding a topic or issue of interest, and
WHEREAS, initial resolutions and their associated whereas clauses may often be kept on file and may be identified as resource documents; therefore be it
RESOLVED, that ‘whereas’ clauses should include evidence-based information and appropriate citations upon the submission of the resolution; and be it further,
RESOLVED, the MSV Rules of Procedure will be updated to reflect this requirement.
10/12/2018 Page 45 Staff Analysis – Resolution 18-108: Establish Evidence-Based Guidelines for MSV Resolutions Submitted by MSV Medical Student Section
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
Strengthen the Currently, the Rules of Benefits: Staff recommends this resolution be This resolution asks MSV to adopt value of MSV Procedure state, “The adopted. revised Rules of Procedure that resolution may carry with it Would ensure that would require whereas clauses in a preliminary statement ‘whereas’ clauses, which Ensuring that each resolution resolutions cite appropriate evidence- explaining the rationale may shape a delegate’s submitted contains factual information based information. behind the resolution, such perception of the that is referenced will allow delegates as preliminary statement, resolution are factual. to be more informed on an issue. preamble, or “Whereas.” While this has traditionally been the Such introductory practice, it would be a positive update statements may: Drawbacks: to include in the Rules of Procedure. identify the problem; advise the House as to None the timeliness or urgency of the problem; advise as to the effect of the problem on the MSV; and indicate if the proposed action is in concert with, or contrary to, current MSV policy
10/12/2018 Page 46 18-109 Amending MSV’s Policy on Balance Billing
Submitted by: Virginia College of Emergency Physicians
WHEREAS, the Medical Society of Virginia policy 10.5.04- Balance Billing, which states “The Medical Society of Virginia supports physician’s ability to accept assignment of benefits and to balance bill patients that have coverage through a managed care organization with whom the physician does not have a contractual relationship” needs to be amended, therefore be it
RESOLVED, that the Medical Society of Virginia amend policy 10.5.04 by substitution as follows:
The Medical Society of Virginia believes that when a patient receives emergency services from an out-of-network physician, the insurer should hold the patient harmless for the cost of the health care services provided, with the exception of the patient’s co-pay, co- insurance, or deductible. An appropriately determined reimbursement should be paid directly and in a timely manner to the physician by the health insurer.
The Medical Society supports policies that will reduce a patient’s risk of receiving a surprise bill. This includes ensuring all emergency services are reimbursed as emergency services, based on the prudent layperson standard; establishing stronger network adequacy requirements; requiring all health plans to contract with any willing provider; and requiring physicians, hospitals and health insurers to provide as much notification as possible for scheduled health care services when a provider is out-of-network.
10/12/2018 Page 47 Staff Analysis – Resolution 18-109: Amending MSV’s Policy on Balance Billing Submitted by Virginia College of Emergency Physicians
Strategic Plan Background MSV Policy Impact on Physicians/Patients Staff Recommendation (RISE) Raise Balance billing is a practice that allows a 10.5.04- Balance Benefits: Staff recommends this perceived value health care provider to bill a patient for the Billing resolution be adopted. of physicians amount not covered by a health plan, which Would allow for patients seek the provider does not contract with. The Medical emergency care without receiving Balanced billing also known as Empower Society of Virginia an additional bill surprise billing is a growing physicians to Balance billing has been the focus of intense supports issue of concern at the state manage Would position physicians as media coverage and recently the Health physician’s ability and federal level. By adopting a change developing a patient friendly Insurance Reform Commission (HIRC) at the to accept solution modified policy, as proposed, it General Assembly. assignment of Would maintain a physician’s will allow MSV the flexibility to benefits and to ability to balance bill for non- work with physician specialty Several states have banned balanced billing balance bill emergent situations societies and patient groups to as a practice – CA, CT, FL, IL, MD, NY. 15 patients that have negotiate a suitable legislative i Would maintain a physician’s more have enacted reform on the issue. Draft coverage through ability to negotiate with health compromise. federal legislation has been released from a a managed care ii plans bipartisan group of Senators in September. organization with Would impose more requirements Legislators have indicated this whom the on plans to reduce arbitrary issue will be before the 2019 A ban on balance billing can reduce a physician does not limitations they can place on General Assembly. It is provider’s ability to negotiate a reasonable have a contractual participation for providers. important that MSV have contract with a health plan. relationship. Allows for assignment of benefits flexibility and not be perceived for emergent out of network care. as fighting against patients or This resolution asks MSV to amend its current an outright ban on balanced policy on balanced billing to: billing will likely be introduced. Drawbacks: hold the patient harmless for costs (other than co-pays, co-insurance, or May limit some physicians ability deductibles) for emergency services; to balance bill
the provider must receive an Could result in inadequate appropriately determined reimbursements for emergency reimbursement directly (assignment care, depending on how of benefits); and appropriate reimbursement is ultimately decided. support additional policies that reduce the patient’s chances of receiving an unexpected bill that address health plans’ practices and encourage all parties to provide advance notice when possible to patients about plan participation.
10/12/2018 Page 48 i “Balance Billing by Health Care Providers: Assessing Consumer Protections Across States,” The Commonwealth Fund. June 2017. DOI: https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_issue_brief_2017_jun_lucia_balance_billing_ib.pdf ii “Analyzing New Bipartisan Federal Legislation Limiting Surprise Medical Bills, “Health Affairs Blog, September 25, 2018. DOI: 10.1377/hblog20180924.442050
10/12/2018 Page 49 18-110
End Surprise Billing
Submitted by: Richmond Academy of Medicine
WHEREAS, it is becoming increasingly difficult for patients to protect themselves from surprise medical bills, and
WHEREAS, patients are often not aware that specialists such as anesthesiologists, radiologist, ER physicians, etc. do not accept their insurance even though the hospital is in network, and
WHEREAS, charges from out-of-network providers contribute to about a third of medical debt cases that non-elderly adults are struggling with, according to a survey conducted by the Kaiser Family Foundation and the New York Times, and
WHEREAS, surprise coverage gaps are created by insurance carriers narrowing networks, a lack of transparency in pricing and costs, and a proliferation of high deductible plans that offer affordable premiums but often leave patients underinsured, and
WHEREAS at the July, 2018 meeting of the Virginia Health Insurance Reform Commission, attendees were told by participating legislators to come up with a solution or the legislators would come up with their own and such solution(s) would likely not be favorable, therefore be it
RESOLVED, that MSV work to mandate that, for a hospital/health system to be considered “in network”, that hospital/health system shall be required to employ or contract with a minimum of one in-network physician for all services offered, and be it further
RESOLVED, that hospitals shall be required to be fully transparent with patients for non-emergent care about whether or not a provider of their service is in or out of network and that the patient be given a choice prior to care for an in or out of network provider. If patient consent or an in-network provider is not available, the hospital/health system shall be responsible for payment of the care balance to the physician, and be it further
RESOLVED, That a Payer network shall be considered “adequate” only if it contains 75% of providers within the hospital/health system’s geographic service area, and be it further
RESOLVED, that the Payer maintain and publicize an accurate and current list of providers, and be it further
RESOLVED, that network adequacy shall be determined by the Virginia Bureau of Insurance, a division of the Virginia State Corporation Commission.
10/12/2018 Page 50 Staff Analysis – Resolution 18-110: End Surprise Billing Submitted by Richmond Academy of Medicine
Strategic Background Plan MSV Policy Impact on Physicians/Patients Staff Recommendation (RISE) Balance billing is a practice that allows a Empower 10.5.04- Balance Benefits: Staff recommends this resolution be not adopted. health care provider to bill a patient for the physicians Billing amount not covered by a health plan, to Would allow for patients While this resolution aims to address the which the provider does not contract with. manage The Medical seeking non- emergency concerns of balanced billing, it raises some change Society of Virginia care to choose their practical and legal concerns. Balance billing has been the focus of supports physician based on their intense media coverage and recently the physician’s ability insurance. Mandating plan participation for physicians is Health Insurance Reform Commission to accept Would improve Virginia’s problematic and may violate MSV policy 10.3.06- (HIRC) at the General Assembly. assignment of network adequacy Freedom of Choice - Patients and Physicians benefits and to requirements and (The Medical Society of Virginia opposes any Current Virginia law on network adequacy balance bill enforcements. legislative program which would prevent free for Medicaid uses a combination of time/ patients that have choice of physician by patient or patient by distance (no more than 30 minutes travel coverage through a physician.) and may run counter to the spirit of time in urban/60 in rural), and number/mix managed care Drawbacks: MSV policy 10.8.06- Physician Hospital Admitting of providers. Where Medicare has stricter organization with Privileges and Plan Participation (The Medical requirements, those are enforced. The whom the Requirement for in-network Society of opposes insurance companies from commercial market physician does not status may not guarantee an terminating or accepting physicians based on the have a contractual available in-network hospital at which they have admitting privileges.) relationship. provider. This resolution asks MSV to support: For routine care, patients have a choice in Focuses primarily on selecting their provider and whether they are A mandate that a hospital/health hospital based care. May in/out of network. For emergency care, EMTALA system must employ or contract with encourage patients to delay requires the treatment of patients without a minimum of one in-network urgent care, if an in-network consideration of their insurance status. physician for all services offered; and provider is not available. For non-emergent care patients be The goal of ensuring the patient has an option for given a choice of an in or out of Could result in non-emergent care must be carefully constructed network provider; hospital/health systems as to not dissuade a patient from seeking care If the patient consents to care and an mandating participation in and creating potential liability concerns. in-network provider is not available, plans as a condition of the hospital/health system shall pay employment. Creating adequacy standards as a percentage of the difference to the physician available providers may pose challenges for A revised definition of network areas without providers, disadvantages adequacy; and telemedicine, and does not consider the current Network adequacy be determined by time/distance requirements under Medicaid and the Virginia Bureau of Insurance. Medicare.
10/12/2018 Page 51 18-111
Improve Balance Billing
Submitted by: Richmond Academy of Medicine
WHEREAS, it is becoming increasingly difficult for patients to protect themselves from surprise medical bills, and
WHEREAS, patients are often not aware that specialists such as anesthesiologists, radiologist, ER physicians, etc. do not accept their insurance even though the hospital is in network, and
WHEREAS, charges from out-of-network providers contribute to about a third of medical debt cases that non-elderly adults are struggling with, according to a survey conducted by the Kaiser Family Foundation and the New York Times, and
WHEREAS, surprise coverage gaps are created by insurance carriers narrowing networks, a lack of transparency in pricing and costs, and a proliferation of high deductible plans that offer affordable premiums but often leave patients underinsured, and
WHEREAS at the July, 2018 meeting of the Virginia Health Insurance Reform Commission, attendees were told by participating legislators to come up with a solution or the legislators would come up with their own and such solution(s) would likely not be favorable, therefore be it
RESOLVED, that MSV supports a physician’s ability to accept assignment of benefits and to balance bill patients that have coverage through a managed care organization with whom the physician does not have a contractual relationship, and be it further
RESOLVED, that MSV work to eliminate payment of assignment of benefit to patients in the instance of payment for physician care, and require those payments be made to physicians.
10/12/2018 Page 52 Staff Analysis – Resolution 18-111: Improve Balance Billing Submitted by Richmond Academy of Medicine
Strategic Background Plan MSV Policy Impact on Physicians/Patients Staff Recommendation (RISE) Raise 10.5.04- Balance Benefits: Staff recommends this resolution be not adopted Assignment of benefits is defined as an perceived Billing and the House reaffirms support for existing arrangement by which a patient requests value of Would maintain current policy 10.5.04- Balance Billing. that their health benefit payments be physicians The Medical policy principle. made directly to a designated person or Society of Virginia This resolution reiterates current policy and is facility, such as a physician or hospital. supports Assignment of benefits duplicative. If the House chooses to adopt physician’s ability resolution 18-109, it may be prudent to ensure This resolution asks MSV to amend its helps to ensure prompt, to accept the support of assignment of benefits to current policy to: direct payment to physicians assignment of for care. physicians, is clearly contained within the final benefits and to policy adopted. Specify that MSV work to ensure balance bill physicians receive direct payment. patients that have Drawbacks: coverage through a managed care None. organization with whom the physician does not have a contractual relationship.
10/12/2018 Page 53
As of October 11, 2018 Resolution 18-112 has been withdrawn at the submitter’s request
10/12/2018 Page 54 18-113
Medical Aid-in-Dying
Submitted by the Richmond Academy of Medicine
WHEREAS, the Medical Society of Virginia (MSV) encourages and supports the use of Advanced Medical Directives – Living Will and Medical Power of Attorney – for all adults in the Commonwealth of Virginia in order for their desires for end-of-life care be known, and
WHEREAS, the Code of Virginia does not presently recognize and allow the compassionate care choice of Medical Aid-in-Dying/Physician Assisted Death to be one of the end-of-life choices now; therefore, be it
RESOLVED, that the Medical Society of Virginia (MSV) support the Commonwealth of Virginia permitting Medical Aid-in-Dying/Physician Assisted Death, with the appropriate safeguards, as an end-of-life choice for adults in the Commonwealth of Virginia.
10/12/2018 Page 55 Staff Analysis – Resolution 18-113: Medical Aid-in-Dying Submitted by Richmond Academy of Medicine
Strategic Impact on Background Plan MSV Policy Staff Recommendation Physicians/Patients (RISE) Medical Aid-in-Dying, is also Empower 25.2.04- Physician Assisted Suicide and Euthanasia Benefits: Given the complex nature known as death with dignity, physicians Date: 11/8/1997 Reaffirmed 10/28/2007, 10/22/2017 and magnitude of the issue, physician assisted dying and/or to manage In dealing with the terminally ill, suffering patient, Would enable if it is the will of the House to physician assisted suicide. This change physicians may ethically: patients seeking an take additional action, the is different than hospice or 1. Withdraw life-prolonging procedures or decline to end of life choice in discussion and implications palliative care. initiate such treatment in situations in which a the Commonwealth of adoption should be patient is terminally ill and has given informed to have access. continued with the MSV In Virginia, the Joint consent for this to be done either personally or Board of Directors and AMA Commission on Health Care through an advance directive, or in instances in Would allow health Delegation to better has been asked to study this which the patient is unable to give such consent it is care providers who understand the implications issue. obtained from an authorized family member or a support aid-in-dying for the Society. surrogate. as an end of life OR, WA, VT, CA, CO, DC, and 2. Prescribe medication to a patient even though the choice the legal HI, all have laws allowing aid- potential exists for inappropriate use by the patient protection to do so. in-dying. Laws across the that may result in death, provided the physician’s country vary in terms of intent in prescribing such medication is not to cause eligibility and process. death or to assist the patient in committing suicide. Drawbacks: 3. In situations where the distinction between The AMA opposes physician relieving suffering and causing a terminally ill May have assisted suicide.i The American patient’s death may be blurred, the physician should significant ethical Academy of Hospice and exercise his/her best medical judgment in caring for and legal Palliative Medicine maintains a the patient. implications for ii neutral position on the issue . 4. Withhold or withdraw treatment from a terminally physicians. The American Public Health ill patient that the physician reasonably believes to Association supports death with be futile either in terms of promoting or improving Wide variety of dignity, under certain the health of the patient or alleviating the patient’s iii positions on the circumstances. suffering, provided the physician’s purpose in so topic; may put the doing is not actively to cause the patient’s death, but MSV at odds with This resolution asks MSV to rather to allow death to occur with minimal suffering. other medical support efforts to permit In accordance with the above statements (which are organizations. Medical Aid-in-Dying/Physician consistent with and supplemented by the views of Assisted Death, with the the Council on Ethical and Judicial Affairs of the appropriate safeguards, as an American Medical Association 2.17, 2.20 and 2.21), end-of-life choice for adults in the Medical Society of Virginia strongly opposes the the Commonwealth of Virginia. practice of physician assisted suicide or euthanasia.
i https://www.ama-assn.org/delivering-care/physician-assisted-suicide
10/12/2018 Page 56 iihttp://aahpm.org/positions/pad iii https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/29/13/28/patients-rights-to-self-determination-at-the-end-of-life
10/12/2018 Page 57 Medical Aid-in-Dying (MAID) Final Report Joint Commission on Health Care
September 18, 2018 Meeting (Rescheduled from August 22 due to time constraint) Michele Chesser, Ph.D. Executive Director
2 Study Mandate
• Delegate Kaye Kory requested via letter that the JCHC study the issue of Medical Aid-in-Dying (MAID). The delegate asked that the study include a review of states that currently authorize MAID and address the following questions: • What has been the impact of informing patients about end-of-life options such as hospice care and palliative care? • In current MAID states, how have health care systems, institutions and providers acted to implement the law? • In current MAID states, have people been coerced to ingest end-of-life medication? • Have any of the states enacted protections to discourage or prevent coercion? • Has the implementation of the law impacted any state’s health care costs? • Using data from states that allow MAID, how many people would likely utilize MAID if it became law in Virginia? • JCHC members approved the study during the Commission’s May 23, 2017 work plan meeting
10/12/2018 Page 58 3 Final Report of Two-Year Study
• Please see the appendix for a copy of the interim report on Medical Aid-in- Dying presented in August, 2017 • Study mandate questions answered in the interim report are not discussed in this final report
4 MAID – U.S. Landscape 4 States with MAID Laws: Oregon (1998) Washington (2008) Vermont (2013) California (2016)* Colorado (2016) Washington, D.C. (2017) Hawaii (2018) By Judicial Review: Montana (2009)
*5.24.18: Judge overturns law; 6.15.18: Judgement is stayed in appeals court. Now legal pending further litigation.
https://www.deathwithdignity.org/news/2016/03/state-progress/ [Updated by M. Chesser]
10/12/2018 Page 59 5 MAID Study Work Group
• As was mentioned during the interim report, a work group was created to discuss Medical Aid-in-Dying • Discussions focused primarily on the reasons to support/oppose MAID, the preferred name of the practice (e.g. MAID vs. Physician Assisted Suicide) and, using Oregon statute as a blueprint, the many components that should be included or removed from the language of any potential Virginia statute • It was established that, for members who oppose MAID, working on language for potential Virginia statute does not indicate support for MAID • Six meetings were held with approximately 20-30 participants per meeting • I would like to thank: • All of the individuals who kindly gave their time and made the effort to participate in the work group • Andrew Mitchell, JCHC analyst, for a great job organizing and facilitating the last year of work group meetings
6 Informing Patients About End-of-Life Options Such as Hospice and Palliative Care • All MAID statutes require that both the attending and consulting physician inform the patient about end-of-life options, including hospice and palliative care • In the states with available data, the great majority of MAID users already were enrolled in hospice and/or had access to palliative care • Oregon: 88.7% (2016); 90.4% (1998-2015) • Washington: 77% (2016); 81% (2015); 69% (2014) • California: 83.8% (2016) received hospice and/or palliative care • Colorado: 92.9% (2017)* • A 2017 study 1 of Kaiser Permanente Southern California’s MAID program showed that of the 68 individuals who died of MAID • 34 (50%) had palliative care at time of MAID inquiry; and the median length of time since first exposure to palliative care services prior to inquiry was 103 days (with a range of 72-397 days) • 38 (56%) had hospice care at time of MAID inquiry; and the median length of time on hospice prior to inquiry was 23 days (with a range of 4-65 days) • Although the study did not provide data on hospice/palliative care rates at time of death, California’s overall rate of 83.8% suggests that additional individuals began receiving hospice and/or palliative care after inquiring about MAID • Legalization of MAID has not resulted in a decrease in use of hospice or palliative care2
* Note: Colorado death data is comprised of individuals who were prescribed MAID medications. Law does not require follow-up data, so the number that died of MAID vs some other cause is unknown. 1. Nguyen et al 2017; 2: Cain 2016, Jackson 2008, Nguyen et al 2017, Each MAID state Data Report
10/12/2018 Page 60 7 Informing Patients About End-of-Life Options Such as Hospice and Palliative Care • Studies of Oregon show that palliative care services spending and patient satisfaction have risen since 1998, when MAID became legal1 • Researchers hypothesized that the request for information on MAID leads to conversations between patients and their physicians about a range of end-of-life options2 • In 2000, a survey of Oregon physicians who had been asked for MAID medication by a patient produced the following results3 • 31 of 67 patients for whom a substantive intervention was made changed their minds about wanting a prescription compared to only 11 of 73 patients for whom no substantive intervention was provided • Substantive interventions included: “control of pain and other symptoms; referral to a hospice program; general reassurance and specific reassurance that the prescription would be made available; treatment of depression; a social work consultation resulting in the provision of services to the family; an alternative means of hastening death; and a palliative care consultation” • Once patients were informed of hospice and enrolled, six percent chose to not use the medication • Note4 that, on average, approximately 1/4 to 1/3 of all individuals who receive a MAID prescription do not use it
1: Cain 2016; 2. Dobscha et al. 2004; 3: Ganzini et al. 2000; 4. Clinical Criteria for PAD document 2015, and each MAID state data reports
In MAID states, how have health care systems, 8 institutions and providers acted to implement the law? • The last 20 years of research show a wide variation in implementation policies/practices among health care systems, hospitals, hospice and palliative care programs and physicians • The majority of researchers conducting studies in MAID states have found that physicians, nurses, social workers, clergy and others in health care systems, institutions or private practice want and need education and guidance on MAID • Some MAID-providing entities have given employees education and/or training on MAID and clear guidelines to follow while others have not • In 2012, Compassion and Choices convened the Physician Aid-in-Dying Clinical Criteria Committee to create guidance for physicians willing to provide MAID to eligible patients* • Committee included experts in medicine, law, bioethics, hospice, nursing, social work and pharmacy* • To view Clinical Criteria document, please go to: https://www.compassionandchoices.org/wp- content/uploads/2016/02/CPG-Supplemental-Data-2015.pdf
*Orentlicher et al 2016
10/12/2018 Page 61 Example of Implementation Challenges: 9 Stanford Health Care, California • Initial experiences highlighted multiple challenges with formal implementation, especially in regard to the disjuncture between an organizational commitment to participate and the legal and ethical right of employees to opt-out • Their policy on conscientious objection requires that the physician maintain indirect involvement with the patient and an institutional commitment to finding an alternative physician; however, difficult due to stigma concerns and challenge of establishing care and prescribing for a colleague’s patient • Challenges in distinguishing between conscientious objection and clinical judgment • Example: MAID vs. cessation of parenteral nutrition • Conference between an ethics consultant, a palliative physician and the attending oncologist resulted in conclusion that the physician’s opinion about the inappropriateness of MAID was a clinical judgement, not conscientious objection • Participating institutions “should develop appropriate mechanisms to review, evaluate, and provide real-time guidance to help address such challenges” (p.908)
Please note: Slide content includes language that is very close to being a direct quote. Source: Harman and Magnus 2017
Example of Implementation: 10 Seattle Cancer Care Alliance, Washington
• Policy written by medical director and approved by simple majority of Medical Executive Committee members • Created informational packets for patients, physicians, and ‘patient advocates’ • Does not accept new patients solely for MAID, instead referred to Compassion and Choices • Does not post the Death with Dignity (DWD) Act or their program in public places • Prior to implementation they offered an institution-wide education program and surveyed clinicians to determine willingness to be a provider (determined to be sufficient number to implement program) • Interested patient is assigned a ‘Patient Advocate’ Please note: Language on this and the following three slides was obtained from Loggers et al. 2013
10/12/2018 Page 62 The Patient Advocate: 11 Assists the patient, family members, pharmacist, and physicians throughout the process Tracks required documentation compliance (sent to Washington Department of Health) Describes the DWD process and the alternatives (specifically, palliative care and hospice, with these services offered as additions to, or in lieu of, DWD) Assesses the patient’s rationale for and interest in further participation If patient elects to participate in the program, the advocate conducts a preliminary chart review to confirm documentation of the terminal prognosis or, if absent, to request that the attending physician document the prognosis explicitly Determines whether the attending physician will act as the prescribing physician. If not, the advocate identifies a prescribing physician and a consulting physician from the list of willing providers, preferentially choosing physicians who specialize in the patient’s type of cancer Formally documents the patient’s request for assistance with dying and provides the patient with written information that describes the program (including a timeline of the required requests, assessments, and waiting periods), which must be signed by the patient Verifies that the patient is a Washington resident and completes a psychosocial assessment. Social workers provide the first line of psychological evaluation for all patients, regardless of whether or not they are participating in the DWD program, using interview-based techniques and standardized assessments. Although physicians retain the responsibility to evaluate patients for depression and decision-making capacity, advocates make these assessments as part of their standard practice. Advocates refer patients to the Psychiatry and Psychology Service if there is any history of, or positive screening for, a mental health disorder or impaired decision- making capacity. The advocate then collects copies of the Physician Order for Life-Sustaining Treatment and health care directives, assisting in their completion if desired
The Patient Advocate: 12 Arranges for a clinician to be present at the time of medication ingestion, if requested (this is rare) Provides advice regarding the securing and disposal of unused medication Provides grief support and legacy support (e.g., help in preparing letters or videos by which to be remembered) through periodic calls or visits Requests that the family inform SCCC when the patient ingests the medication, so that staff can provide assistance in the case of complications, offer bereavement support, and aid the prescribing physician in completing the required after-death reporting forms Participates in two in-person meetings with the patient and family on average (range, one to four); and use of telephone follow- up is possible
10/12/2018 Page 63 Example of Implementation: 13 Seattle Cancer Care Alliance, Washington (Cont’d)
• The patient (and family) meets sequentially with the prescribing clinician and the consulting clinician to review the medical diagnosis, prognosis, risks of medication, and alternatives (including palliative and hospice care) • After the mandatory waiting period of 15 days, if all requirements are met, a written prescription is given to the SCCA retail pharmacy. The pharmacist schedules a private room to meet with the patient (and family) in order to discuss preparation of the drug for ingestion, potential side effects, and the use of antiemetic therapy • Checklists and medical charts are randomly audited annually by the director of supportive care and specialty clinics • They have had “100% compliance with the completion of mandated forms and processes, with the exception of one unintentional failure to observe the full waiting period early in our program” • “Our Death with Dignity program has been well accepted by patients, families, and staff” • Due to: professionalism of advocates, “great care taken by our prescribing and consulting clinicians when interacting with patients and families”, low profile of the state program, willingness of leadership to allow “considerable debate” before the program was developed (p.1422) • Some of the physicians that originally opposed the program later agreed to participate
14 How MAID Law Has Been Implemented by Hospice Programs
• A 2012 study by Campbell and Cox indicated that most Oregon hospice programs set programmatic, professional, and moral boundaries to their involvement in MAID deaths • For example: due to post-ingestion complications, primarily regurgitation, in 1 in 20 cases, several hospices developed policy that staff can address “human” needs regarding comfort and safety (e.g. providing anti-nausea medication), but not “medical” needs (which are the domain of the physician) • Another study found that limits were set regarding “(a) providing information to the patient, (b) notifying the primary physician of the patient’s request, (c) providing or assisting with the medications necessary to hasten a patient’s death, and (d) permitting the presence of staff members at ingestion or death.”*
*Norton and Miller 2012
10/12/2018 Page 64 15 Coercion and Fraud
• Penalties for coercion and fraud included in states’ statutes: • Oregon: Class A felony • Washington: Class A felony • Vermont: Unable to find section on coercion/fraud • California: A felony • Colorado: Class 2 felony • D.C.: Class A felony • One can assume it is possible that some instances of coercion or fraud in MAID states may have occurred; however… • it may not have been witnessed or interpreted as coercion or fraud, or • substantiating the claim may not have been successful • However, to date, unable to find cases of substantiated accusations of fraud or coercion • It is possible that current penalties are sufficient to discourage coercion and fraud
1 Has the implementation of the law 6 impacted any state’s health care costs?
• States are not allowed to use federal Medicaid or Medicare funds to pay for MAID services • As a result, some states utilize state funds to pay for MAID among Medicaid enrollees • However, given the relatively low cost of MAID medications and additional physician visits required during the MAID process coupled with the very low percentage of individuals participating in MAID who also are enrolled in Medicaid, cost to the state is minimal
10/12/2018 Page 65 17
Recommended Statute Language if Legislation is Introduced in Virginia
Statute Language: 18 Areas of Work Group Member Disagreement*
• Term used in statute (e.g. MAID vs Physician Assisted Suicide) • Accuracy of “terminal illness (likely death in ≤ 6 months)” language • Overall, balance in language between safeguards and access to MAID • Requirements necessary to recognize and prevent individuals from using MAID whose judgment is impaired by depression • Potential for discrimination against the disabled and other vulnerable groups • For example, use of the term self-administer vs. ingestion • Need for additional language to further decrease the likelihood of coercion • Definition of informed decision • Voluntarily expressing wish to die (relating to forms of communication) *Please see in appendix the 4 Compassion and Choices slides and the 4 “10 Reasons to Oppose Physician Assisted Suicide” slides for examples of arguments in support of and in opposition to MAID
10/12/2018 Page 66 MAID Component (MAID State Statutes That Include It) 19 Attending MD Requirements Confirm Patient Eligibility • Requesting individual must: • Be 18+ years old (all 6) • Be State resident (all 6) • Be capable of decision making (all 6) • Voluntarily express wish to die (all 6) • Have a terminal illness (likely death in ≤ 6 months) (all 6) Ensure Informed Consent • Inform patient of: • Diagnosis and prognosis (all 6) • Risks and probable result of MAID medication (all 6) • Alternatives including comfort care, hospice, pain control (all 6) and treatment available for terminal disease (VT) • His/her right to rescind request at any point (all 6) • Possibility that patient can obtain MAID medication but not take (CA, CO) • Confirm that decision is not coerced through a private conversation (CA, CO) • Refer to 2nd physician for confirmation (all 6) • Refer to counseling if determined to be appropriate (if indications of mental impairment [CA]) (all 6) Provide information on process • Recommend patient notify next of kin of request (OR, CA, DC, WA) • Counsel patient about having another person present when taking medication and not taking in a public place (OR, CA, CO, DC, WA) • Counsel patient on enrolling in hospice (CA) • Counsel patient on storing medication safely (CA, CO) • Offer patient opportunity to rescind at 2nd oral request (OR, CA, DC, VT, WA) • Give patient final attestation form to be completed/signed ≤ 48 hours of self-administering MAID medicine (CA)
MAID Component (MAID State Statutes That Include It) 20 Prescribing/ Dispensing • Verify patient is making informed consent immediately prior to writing prescription (all 6) • No prescription to be filled if psychiatric or psychological illness present (OR, CA, CO, DC, WA) • No prescription to be filled if patient has not made voluntary/informed decision (OR, CA, CO, DC, WA) • Dispense MAID medication directly or, with patient’s written permission, via pharmacist to patient or designated agent (all 6) Other • Attending MD, consulting physician, mental health providers may not be related to patient or entitled to patient’s estate (CA) Fulfill reporting and documentation requirements • Must document in patient’s medical record: • All oral/written requests by patient (all 6) • Diagnosis, prognosis, verification that patient is capable, acting voluntarily, making informed consent (by attending and consulting MDs) (all 6) • Outcome of counseling, if performed (all 6) • Offer to patient to rescind request (all 6) • Note that all requirements have been met and medication prescribed (all 6) • Final attestation form signed by patient, returned to attending MD, for inclusion in medical record (CA) • Attestation that patient enrolled in hospice or informed of EOL services (VT) • Submit records to health authority (CA, DC, VT) ≤ 30 days of writing prescription of patients death (CA, DC) • Records exempt from disclosure (CA, CO, WA) • May sign death certificate indicating disease as cause of death (all 6) Consulting MD responsibility • Examine patient, medical records (all 6) • Confirm in writing attending MD diagnosis (all 6) • Verify patient is capable and acting voluntarily (all 6) • Refer to counseling if appropriate (all 6)
10/12/2018 Page 67 MAID Component (MAID State Statutes That Include It) 21 Patient requirements Form of request • Make oral and written requests (all 6) directly to attending MD (CA) • Written request substantially in form provided in Statute (OR, CA, CO, DC, WA), must use form in statute (CA) • Written request signed/dated with 2 witnesses (all 6), given directly to MD (CA) • 2nd oral request to attending MD ≤ 15 days after initial (all 6) • Attending MD cannot write prescription until ≥ 15 days after initial oral request and ≥ 48 hours after written request (OR, DC, VT, WA) Witness requirements • ≥ 2 adults (all 6) • witnesses personally known or provided patient ID (CA) • Only 1 witness may be (CA) • Related by blood, marriage, adoption (all 6) • Heir (OR, CA, CO, DC, WA) • Owner/operator/employee of facility where patient treated (CA) • 0 witnesses may be attending MD, consulting physician, mental health specialist (CA) • If patient in nursing facility, 1 witness may be person designated by facility (0) • Witnesses attest that patient is capable, acting voluntarily, not coerced (all 6) Other Regulatory follow-up and public reporting requirements • Oversight agency will: • Adopt rules to facilitate collection of information re: compliance (OR,CO, DC, VT, WA) • Generate and make public annual statistical report of information collected, adhering to HIPA (OR, CA, CO, DC, WA) • Provide an online guidebook and establish training opportunities for medical community to learn about the MAID process and medications that may be used • Rules for safe disposal of unused meds by persons in custody of meds (CA, CO)
MAID Component (MAID State Statutes That Include It) 22 Immunities • Immune from civil or criminal prosecution for any person solely for being present when patient takes medication (all 6) • Providers are immune from disciplinary action, revocation of licenses/privileges for prescribing lethal meds under terms of law (all 6) • No provider compelled to participate (other than transferring records) (all 6) • Provider can prohibit other providers (employees, contractors) from participating on facility premises/acting under providers’ employment if written policy in place and provider notified (all 6) • Provider cannot prohibit independent contractors/employees from participating outside scope of contract/employment or off premises (OR, CA, DC, VT, WA) • Sanctions can be imposed on providers participating against policy (all 6) • No effect on life or health insurance policies or annuities; health care service plan contract (CA) or health benefit plan (CA) (all 6) • No effect on will, contract, other agreement (OR, CA, CO, DC, WA) • Does not sanction mercy killing, active euthanasia, lethal injection (all 6) • Actions under law ≠ suicide, assisted suicide, homicide (all 6) • Participation ≠ elder abuse, neglect (OR, CA, CO, WA) Liabilities • Forging prescription, coercion into request, concealing or destroying rescission of request is Class A felony (OR, CA, DC, WA) • Administering medicine to individual without consent is felony (CA, CO, DC) • Government can make claims against individual if death occurs in public place causing expenses (all 6)
10/12/2018 Page 68 23
Additional Options to Consider Improving End of Life Care in Virginia
Note: The following eight slides (or some slide content) are used with permission from the Virginia POST Collaborative and Capital Caring
Most Adults Don’t Have Any 24 Advanced Care Planning Documents…
• Only 25% of adults have advance directives • What happens if there is no plan? • State determines the legal health care decision maker • Medical treatments are not limited in an emergency • Decision makers, families, health care providers struggle to determine what the patient would want • O en this leads to…
10/12/2018 Page 69 25 I Want Everything Done (or the presumption of this desire)
26 Virginia Physician Orders for Scope of Treatment (POST)
• The Virginia Physician Orders for Scope of Treatment (POST) Form Set is a portable medical order that, in the intended population as identified by the National POLST Paradigm, is recognized as a medical best practice for eliciting, documenting and honoring a patient’s medical wishes • Virginia’s POST Program received endorsement from the National POLST Paradigm in 2016 (the 19th state to earn this recognition) • The POST form set is intended to be used during a time of advanced illness • Unlike an Advance Directive (signed by patient) and Do Not Resuscitate directive (signed by provider), the POST form set is created during a conversation between the physician and patient/patient agent (if patient is unable to communicate) and signed by the patient/patient agent and the physician • Unlike the AD, which usually is created, most often, earlier in one’s life and then held in suspension, the POST form set is created when a person is determined to have serious illness; therefore, it can provide specific orders within that context with the specific illness/condition in mind • As a result, it is considered to be an important addition to an AD or DNR
Sources: Hickman and Critser 2018; POST Collaborative slide content; and communication with Dr. Matt Kestenbaum (Virginia POST) and National POLST Paradigm staff
10/12/2018 Page 70 27
28
10/12/2018 Page 71 29
30
10/12/2018 Page 72 Roadblock to Wide-Spread Use 31 of POST Form Set in Virginia
• § 54.1-2987.1 of Virginia Code does not specifically mention POST and 12VAC5-66-10 of Administrative Code only specifically mentions POST in DNR section, but on POST form that is only Section A of a set of questions/orders. Remaining parts are not specifically about DNR • Writers of the Code section thought language was specific enough; however, legal counsel of some health care systems and hospitals have advised against using the POST form set • POST experts believe that an Opinion from Virginia’s Attorney General that the Code language does apply to the POST form set, in full, would address the problem • If AG Opinion is that Code does not apply to POST, legislation to change the Code and, perhaps, an official memo from the Virginia Board of Health assuring/clarifying that the POST form set is recognized as a medical best practice for eliciting, documenting and honoring a patient’s medical wishes are needed
32 Policy Options
Option 1: Take no action Option 2: Introduce legislation to amend the Code of Virginia to include a Medical Aid-in-Dying statute that mirrors California’s EOLOA statute, with the following additions: a. when informing patient of alternative to MAID, attending physician must include information about any possible treatments for the underlying disease, b. attending physician must attest that patient enrolled in hospice or was informed of EOL services , c. if patient is in nursing facility, one witness may be person designated by facility, d. adopt rules to facilitate collection of information regarding compliance, e. provide an online guidebook and establish training opportunities for medical community to learn about the MAID process and medications that may be used (NOTE: Language will be provided to members and placed on the JCHC website 5 business days prior to the November Decision Matrix meeting) Option 3: By letter of the JCHC Chair, request that the Attorney General provide an opinion as to whether Virginia Code and regulation language regarding DDNRs and other orders regarding life-prolonging procedures applies to POST form sets, including parts A, B, C and D. If opinion is that language does not apply, also: Option 3a: Introduce legislation to change the Code of Virginia (including Administrative Code) to insert “POST form set” into Virginia statute relating to orders regarding life-prolonging procedures Option 3b: By letter of the JCHC Chair, request that the Virginia Board of Health review the POLST Paradigm and create official memo assuring/clarifying that the POST form set is recognized as a medical best practice for eliciting, documenting and honoring a patient’s medical wishes
10/12/2018 Page 73 33 Policy Options
Option 4: Introduce legislation to amend the Code of Virginia to require health regulatory boards of physicians, nurse practitioners, and physician assistants to promulgate regulations providing for the satisfaction of a one-time POST form set continuing education requirement of 0.5 – 1 hour for new licensure or re-licensure Option 5: Place on the list of potential JCHC studies in 2019 a mini-study to obtain data, via a survey of health care systems and independent hospitals, on the degree to which these entities offer end-of-life planning. (For example, the number of Advanced Care Planning facilitators employed, if a patient indicates that he/she does not have an Advance Directive, does the entity have policy designed to guide staff on whether, and if so, how to discuss the topic with the individual, etc.) Option 6: By letter of the JCHC Chair, request that the Virginia Department of Health consider the development of a unique POST registry that is accessible from various electronic medical records, allows electronic completion and is accessible in real- time by first responders (which is not the case with the current AD registry).
34 Public Comment Slide
Written public comments on the proposed policy options may be submitted to JCHC by close of business on October 15, 2018. Comments may be submitted via: E-mail: [email protected] (Please do not submit to staff email address, which creates potential for your comments to unintentionally be missed.) Fax: 804-786-5538 Mail: Joint Commission on Health Care P.O. Box 1322 Richmond, Virginia 23218
Comments will be provided to Commission members and summarized during the November 21st decision matrix meeting.
(Please Note: All public comments are subject to FOIA release of records)
10/12/2018 Page 74 35
Appendix
Medical Aid in Dying Laws Protect Patients
Medical Aid in Dying gives patients autonomy. The patient is in charge. They request the medication. They take it. And they can change their mind at any time. Not a single case of abuse or coercion nor any criminal or disciplinary charges have ever been filed. Not one, in a combined 40+ years where MAID is authorized.
Research shows just having medical aid in dying as an option relieves fear and anxiety — even for those who never choose the option.
This slide, and the following 3 slides, submitted by C & C in support of MAID
10/12/2018 Page 75 Medical Aid in Dying Laws Protect Patients
Core Safeguards for Medical Aid in Dying
➢ Strict eligibility criteria. ➢ Two doctors must confirm that the patient has six months or less to live — due to terminal illness, not because of age or disability.
➢ Two doctors must also both confirm the patient is capable of making their own healthcare decisions and that no coercion exists.
➢ Coercion is subject to criminal prosecution.
Medical aid in dying is not suicide. Suicide often involves people who are severely depressed and no longer want to live. People who seek medical aid in dying are suffering life-ending illnesses and understand that their condition is no longer treatable—there is no hope for a better outcome. Those considering suicide see no hope and do not recognize that their problems are treatable.
Medical aid in dying is fundamentally different from euthanasia. Medical aid in dying is authorized in seven states as well as the District of Columbia. With medical aid in dying, the terminally ill person must take the medication themselves, and therefore, always remains in control. Euthanasia is commonly given as a lethal injection by a third party. It is often performed on somebody who does not have a terminal diagnoses and is illegal throughout the United States.
10/12/2018 Page 76 Broad Support for Medical Aid in Dying
Ten Reasons to Oppose Physician-Assisted Suicide* 36 (Submitted by Opposing Work Group Members)
1. Assisted suicide is a deadly mix with our broken, profit-driven health care system Financial pressures already play far too great a role in many, if not most, health care decisions. Direct coercion is not even necessary. If insurers deny, or even merely delay, approval of expensive, life-giving treatments that patients need, patients will, in effect, be steered toward assisted suicide, if it is legal. Barbara Wagner and Randy Stroup, Oregonians with cancer, were both informed by the Oregon Health Plan that the Plan won’t pay for their chemotherapy, but will pay for their assisted suicide. Though labeled a free choice, for these patients, assisted suicide is a phony form of freedom. 2. Assisted suicide is dangerous to people with disabilities and many other people in vulnerable circumstances. There is considerable evidence that people with mental illness and depression are given lethal drugs in Oregon, despite the claims of proponents that these conditions disqualify a person. (See testimony by Dr. Gregory Hamilton focusing on problems posed by assisted suicide in Oregon for people with psychiatric disabilities). 3. Available statistics show that pain is rarely the reason why people choose assisted suicide. Most people do so because they fear burdening their families or becoming disabled or dependent. But anyone dying in discomfort that is not otherwise relievable, may legally today, in all 50 states, receive palliative sedation, wherein the patient is sedated to the point where the discomfort is relieved while the dying process takes place. Thus, today there is a legal solution to any remaining painful and uncomfortable deaths; one that does not raise the very serious difficulties of legalizing assisted suicide.
* These reasons are adapted from the Disability Rights Education & Defense Fund’s “Key Objections to the Legalization of Assisted Suicide”.
10/12/2018 Page 77 Ten Reasons to Oppose Physician-Assisted Suicide, Cont’d 37 (Submitted by Opposing Work Group Members)
4. The supposed safeguards included in the Oregon and Washington State laws don’t really protect patients for many reasons, including these: • If a doctor refuses lethal drugs, the patient or family simply can – and do – find another doctor (“doctor shopping”). • “Sixon The Fundamental Loophole of Terminal Illness Prognosis) • Nothing in the Oregon law will protect patients when there are family pressures, whether financial or emotional, which distort patient choice. • An article from Michigan Law Review, June 2008, shows how the State of Oregon undermines all the safeguards in the law. Physician Assisted Suicide: A Medical Perspective (PDF) by Dr. Herbert Hendin and Dr. Kathleen Foley. Herbert Hendin is Chief Executive Officer and Medical Director, Suicide Prevention International, and Professor of Psychiatry, New York Medical College. Kathleen Foley is Attending Neurologist, Memorial Sloan-Kettering Cancer Center; Professor of Neurology, Neuroscience, and Clinical Pharmacology, Weill Medical College of Cornell University; and Medical Director, International Palliative Care Initiative of the Open Society Institute. • months to live” is often wildly misdiagnosed, opening the dangers of assisted suicide to many who are not terminally ill. (See the DREDF statement 5. Problems with Oregon’s data collection and data soundness, and the lack of any investigations of abuse or meaningful oversight, are so significant as to render conclusions based on those data to be critically flawed. Oregon doctors are not penalized for failing to report assisting in a suicide. The state does not investigate cases of expansion and complications reported in media, and have admitted, “We cannot determine whether physician assisted suicide is being practiced outside the framework of the Death with Dignity Act.” The state has also acknowledged actually destroying the underlying data after each annual report. (Regarding abuses that have come to light in Oregon, see handout on Oregon abuses (PDF). Regarding the destruction of data, see testimony of Dr. Katrina Hedberg, 9 December 2004, House of Lords, Select Committee on the Assisted Dying for the Terminally Ill Bill, Assisted Dying for the Terminally Ill Bill [HL], Volume II: Evidence, (London: The Stationery Office Ltd., 2005), 262.)
Ten Reasons to Oppose Physician-Assisted Suicide, Cont’d 37 (Submitted by Opposing Work Group Members)
6. There is research strongly suggesting Oregon has seen a reduction in the quality of palliative care at the end-of-life since the Oregon law went into effect. An important study published in 2004 in the Journal of Palliative Medicine showed that dying patients in Oregon are nearly twice as likely to experience moderate or severe pain during the last week of life, as reported by surviving relatives, compared with patients before the Oregon law took effect. An op-ed in The Oregonian on July 23, 2004 stated, “The findings call into question the widespread view that pain control at the end of life has improved markedly in Oregon.” (Journal of Palliative Medicine, Volume 7, Number 3, 2004, p. 431) While it is true that Oregon has shown improvements in some areas of end-of-life care, similar improvements have occurred in other states that have not legalized assisted suicide. As Doctors Kenneth Stevens and William Toffler noted on September 24, 2008 in The Oregonian, many states do better than Oregon. For example, the latest data ranks Oregon 9th (not 1st) in Medicare-age use of hospice; four out of the top five are states that have criminalized assisted suicide. Physicians are acknowledging that legalizing assisted suicide creates pressure to die rather than continue with beneficial hospice care (Ira Byock, MD, The Atlantic). 7. Some 24 states have rejected the legalization of assisted suicide since Oregon passed its law. We should heed their significant public policy concerns.
10/12/2018 Page 78 Ten Reasons to Oppose Physician-Assisted Suicide, Cont’d 37 (Submitted by Opposing Work Group Members)
8. Many key organizations oppose the legalization of assisted suicide. • Including the AMA and all 50 of its state affiliates; the National Hospice and Palliative Care Organization; many prominent Democrats and liberals including Bill Clinton, Ralph Nader, and noted civil liberties journalist Nat Hentoff; many disability rights organizations; and the League of United Latin American Citizens (LULAC, national level). • The AMA’s Council on Judicial and Ethical Affairs reported this year that “the term ‘physician assisted suicide’ describes the practice with the greatest precision…The terms ‘aid in dying’ or ‘death with dignity’ could be used to describe either euthanasia or palliative/ hospice care at the end of life and this degree of ambiguity is unacceptable for providing ethical guidance.” (CEJA Report 5-A-18) 9. Suicide requests from people with terminal illness are usually based on fear and depression. As Herbert Hendin, M.D., Chief Executive Officer and Medical Director, Suicide Prevention International, and Professor of Psychiatry, New York Medical College, stated in Congressional testimony in 1996, "a request for assisted suicide is … usually made with as much ambivalence as are most suicide attempts. If the doctor does not recognize that ambivalence as well as the anxiety and depression that underlie the patient’s request for death, the patient may become trapped by that request and die in a state of unrecognized terror.” Most cases of depression among terminally ill people can be successfully treated. Yet primary care physicians are generally not experts in diagnosing depression. Where assisted suicide is legalized, the depression remains undiagnosed, and the only treatment consists of a lethal prescription. 10. Physician-assisted suicide is not a private, personal act. Physician-assisted suicide involves more than the patient. It necessitates a host of participants, including a doctor, a pharmacist, and the state. It's a public act that requires medicine, law, and society approve a lethal prescription that crosses the line between caring and killing. Significant issues of conscience are implicated for all the parties directly or indirectly involved.
44
Interim MAID Report
10/12/2018 Page 79 Medical Aid-in-Dying (MAID) Interim Report Joint Commission on Health Care
August 22, 2017 Meeting
Michele Chesser, Ph.D., Executive Director
* I would like to thank Meagan D. Sok, JCHC Intern, for her work on this study
46 Study Mandate
Delegate Kaye Kory requested via letter that the JCHC study the issue of Medical Aid-in- Dying (MAID). The delegate asked that the study include a review of states that currently authorize MAID and address the following questions: What has been the impact of informing patients about end-of-life options such as hospice care and palliative care? In current MAID states, how have the following acted to implement the law? Health care providers Health care systems Health care institutions In current MAID states, have people been coerced to ingest end-of-life medication? Have any of the states enacted protections to discourage or prevent coercion? Has the implementation of the law impacted any state’s health care costs? Using data from states that allow medical aid-in-dying, how many people would likely utilize medical aid-in-dying if it became law in Virginia? JCHC members approved the study during the Commission’s May 23, 2017 work plan meeting
10/12/2018 Page 80 41 MAID Study Work Group
A work group was created to discuss Medical Aid-in-Dying and consider components of the statute that will be one of the policy options Meeting 1: July 25, 2017 Overview of issue presented by Dr. Chesser Discussion of MAID Meeting 2: August 25, 2017 Discussion of policy options and statute components Meeting 3: TBD Discussion of statute components
48 MAID Study Work Group
• ALS Association • INOVA • Virginia Commonwealth University Health System • American Cancer Society • Mary Washington Healthcare • VDH • American Lung Association • Medical Society of Virginia • Virginia Association of Health Plans • Anthem • NAMI • Virginia Association for Hospices • Bon Secours • Office of the Secretary of Health and and Palliative Care • Capital Caring Human Resources • Virginia Catholic Conference • Carilion • Riverside Health System • Virginia Centers for Independent • Compassion and Choices • Robert Misbin, MD Living • DARS • Senior Navigator • Virginia Health Care Association • DBHDS • Sentara • Virginia Hospital and Healthcare • DHP • Social Worker, Diane Kane Association • Virginia Nurses Association • DisAbility Law Center • Society for Critical Care Medicine • Virginia Public Access Project • DMAS • The Arc of Virginia • Family Foundation • Virginia Society for Human Life • University of Virginia • HCA Healthcare Virginia • Virginia Trial Lawyer Association • Virginia Association of Health Plans
10/12/2018 Page 81 49 Definition of Medical Aid-in-Dying
• The ability of a patient to obtain a medication to end their life if they are competent, terminally ill, and over 18 years of age
• The ability of a physician to prescribe a medication that will allow a competent, terminally ill individual over the age of 18 to end their life • Some individuals/organizations prefer to use terms like assisted suicide • However, different legal definition with implications if worded as such in Virginia statute
50 Current Virginia Statute
• § 8.01-622.1. Injunction against assisted suicide; damages; professional sanctions. • A. Any person who knowingly and intentionally, with the purpose of assisting another person to commit or attempt to commit suicide, (i) provides the physical means by which another person commits or attempts to commit suicide or (ii) participates in a physical act by which another person commits or attempts to commit suicide shall be liable for damages as provided in this section and may be enjoined from such acts. • B. A cause of action for injunctive relief against any person who is reasonably expected to assist or attempt to assist a suicide may be maintained by any person who is the spouse, parent, child, sibling or guardian of, or a current or former licensed health care provider of, the person who would commit suicide; by an attorney for the Commonwealth with appropriate jurisdiction; or by the Attorney General. The injunction shall prevent the person from assisting any suicide in the Commonwealth. • C. A spouse, parent, child or sibling of a person who commits or attempts to commit suicide may recover compensatory and punitive damages in a civil action from any person who provided the physical means for the suicide or attempted suicide or who participated in a physical act by which the other person committed or attempted to commit suicide. Emphasis added
10/12/2018 Page 82 51 Current Virginia Statute, Continued
• D. A licensed health care provider who assists or attempts to assist a suicide shall be considered to have engaged in unprofessional conduct for which his certificate or license to provide health care services in the Commonwealth shall be suspended or revoked by the licensing authority. • E. Nothing in this section shall be construed to limit or conflict with § 54.1-2971.01 or the Health Care Decisions Act (§ 54.1-2981 et seq.). This section shall not apply to a licensed health care provider who (i) administers, prescribes or dispenses medications or procedures to relieve another person's pain or discomfort and without intent to cause death, even if the medication or procedure may hasten or increase the risk of death, or (ii) withholds or withdraws life-prolonging procedures as defined in § 54.1-2982. This section shall not apply to any person who properly administers a legally prescribed medication without intent to cause death, even if the medication may hasten or increase the risk of death. • F. For purposes of this section: • "Licensed health care provider" means a physician, surgeon, podiatrist, osteopath, osteopathic physician and surgeon, physician assistant, nurse, dentist or pharmacist licensed under the laws of this Commonwealth. • "Suicide" means the act or instance of taking one's own life voluntarily and intentionally. • 1998, c. 624; 2015, c. 710.
Emphasis added
52
Existing Medical Aid-in-Dying Statutes
10/12/2018 Page 83 53 MAID: U.S. Landscape
States with MAID Laws: Oregon (1998) Washington (2008) Vermont (2013) California (2016) Colorado (2016) Washington, D.C. (2017)
*By Judicial Review, legal in Montana (2009): Nothing in the state law prohibits MAID. Physicians cannot be prosecuted so long as the patient is competent, terminally ill, at least 18 years of age and acting voluntarily
https://www.deathwithdignity.org/news/2016/03/state-progress/
54 2017 State Actions
Status of bills and court cases as of July 2017. Source: https://www.nytimes.com/2017/08/05/opinion/sunday/dying-doctors-palliative-medicine.html
10/12/2018 Page 84 55 Generally, Existing MAID Statutes Include:
Eligibility Criteria: Process: • Attending and consulting physicians determine and agree that the • Adult, 18 years of age and older patient suffers from a terminal disease with less than six months to live. • Resident of the state • Patient must provide 2 voluntary oral requests no less than 15 days • Suffer from a terminal illness apart. • Able to self-administer the medication • Patient must provide a signed written request (form provided) for the medication, co-signed by 2 witnesses • Physician to provide prescription at least 15 days after the initial oral request and at least 48 hours after the signed request. • Before providing the prescription, the physician must confirm the Requires physician provide the following to patient has not rescinded the request and remind the patient that the the patient: patient is not required to ingest the medication. • If either physician believe the patient is suffering from depression or 1. Diagnosis with prognosis any behavioral health condition that may be impacting their choice, 2. Range of options including palliative care they are to refer the patient to a psychiatrist before proceeding. and hospice care • For prescription: After obtaining patient approval, attending physician 3. Risks and probable death from calls pharmacy to alert pharmacist of the prescription to be filled and prescription sends the written prescription through specified means. • When ingesting, patient must self-administer the medication.
56 Oregon (1998 Statute)
• Eligibility: Oregon resident, determined by attending and consulting physician to have a terminal disease, and voluntarily expressed wish to die • Consulting physician shall examine the patient and relevant medical records and confirm, in writing, the attending physician’s diagnosis that the patient is suffering from a terminal disease, and verify that the patient is capable, is acting voluntarily and has made an informed decision. • Counseling: If either physician believes the patient may have a mental health disorder (including depression) causing impaired judgement, the physician may refer the patient for counseling. Medication can only be prescribed if the counselor determines that the patient does not have impaired judgement resulting from a mental health condition • Patient Request: Patient must provide two oral requests no less than 15 days apart, and a written request witnessed by two people • Prescription cannot be provided less than 15 days from initial oral request and less than 48 hours after written request
10/12/2018 Page 85 57 Oregon (1998 Statute) Continued (2)
• Witnesses: Must attest that to the best of their knowledge the patient is capable, acting voluntarily, and is not being coerced to sign the request. One of the witnesses shall be a person who is not: • A relative of the patient by blood, marriage or adoption; • A person who at the time the request is signed would be entitled to any portion of the estate of the qualified patient upon death under any will or by operation of law; or • An owner, operator or employee of a health care facility where the qualified patient is receiving medical treatment or is a resident. • The patient’s attending physician at the time the request is signed shall not be a witness • If the patient is in a long term care facility at the time the written request is made, one of the witnesses shall be an individual designated by the facility and having the qualifications specified by the Department of Human Services
58 Oregon (1998 Statute) Continued (3)
• Informed Decision: The attending physician, to ensure that the patient is making an informed decision, shall inform the patient of: • His or her medical diagnosis and prognosis • The potential risks associated with taking the medication to be prescribed • The probable result of taking the medication to be prescribed • The feasible alternatives, including, but not limited to, comfort care, hospice care and pain control • Immediately prior to writing the prescription for medication, the attending physician must verify that the patient is making an informed decision • The attending physician also shall: • Recommend the patient notify next of kin • Counsel the patient about the importance of having another person present when the patient takes the medication and of not taking the medication in a public place (e.g. a hotel room, park) • Inform the patient that he or she has an opportunity to rescind the request at any time and in any manner, and offer the patient an opportunity to rescind at the end of the 15 day waiting period • Document all steps of the MAID process in the patient’s medical record
10/12/2018 Page 86 59 Oregon (1998 Statute) Continued (4)
• Dispensing of Medication: The physician shall dispense medications directly if he/she is registered as a dispensing physician or, with the patient’s consent, contact a pharmacist and inform the pharmacist of the prescription and deliver the written prescription personally or by mail to the pharmacist, who will dispense the medications to either the patient, the attending physician or an expressly identified agent of the patient • Reporting Requirements: The physician shall fill-out and submit to the Center for Health Statistics required forms when medicine was prescribed (including the dispensing record) and after death. The Department of Human Services shall generate and make publically available an annual statistical report of de-identified, aggregate information. • Liabilities: Fraud and coercion are a Class A Felony • Effect on Construction of Wills, Contracts or Statutes: • No provision in a contract that would effect whether a person engages in MAID shall be valid. • The sale, procurement, issuance or rate of life, health, or accident insurance shall not be effected by MAID. In addition, ending one’s life utilizing MAID shall not have an effect upon a life, health, or accident insurance or annuity policy. • Nothing in this statute shall be construed to authorize a physician or any other person to end a patient’s life by lethal injection, mercy killing or active euthanasia. Actions taken in accordance with this statute shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide, under the law.
60 Oregon (1998 Statute) Continued (5)
• Immunities and Opting-Out: No one shall be punished for choosing to participate or not participate in MAID. Participation in MAID shall be voluntary. If a health care provider is unable or unwilling to carry out a patient’s request the physician can transfer the patient to a new provider (which includes a new physician or new facility) • However, a provider (facility/health care system) may prohibit another provider (physician) from participating in MAID on the premises of the prohibiting provider if the prohibiting provider has notified the health care provider of the prohibiting provider’s policy regarding participating in MAID. If the provider engages in MAID, he/she can receive sanctions within the context of the facility/health care system. • Suspension or termination of staff membership or privileges due to prohibited participation in MAID is not reportable under ORS 441.820 and shall not be the sole basis for a report of unprofessional or dishonorable conduct under ORS 677.415 (2) or (3) • A health care provider can participate in MAID while acting outside the course and scope of the provider’s capacity as an employee or independent contractor; and a patient can contract with his or her attending physician and consulting physician to act outside the course and scope of the provider’s capacity as an employee or independent contractor of the sanctioning health care provider.
10/12/2018 Page 87 61 Oregon (1998 Statute) Continued (6)
• Cause of death on death certificate is the terminal illness • A request by a qualified individual to an attending physician to provide an aid-in-dying drug shall not provide the sole basis for the appointment of a guardian or conservator. • Claims by governmental entity for costs incurred: Any governmental entity that incurs costs resulting from a person terminating his or her life in a public place shall have a claim against the estate of the person to recover such costs and reasonable attorney fees related to enforcing the claim
62 Statutes: What Other States Have Done Differently
• Most states and D.C. used the Oregon statute as a blueprint • CA: The attending physician, consulting physician, or mental health specialist shall not be related to the individual by blood, marriage, registered domestic partnership, or adoption, or be entitled to a portion of the individual’s estate upon death • VT: Physician must inform the patient, in writing, of their diagnosis, prognosis, and range of treatment options including hospice and palliative care • DC: Inform the patient of the availability of supportive counseling to address the range of possible psychological and emotional stress involved with the end stages of life • CO: Attending physician must confirm no coercion or undue influence by having a private conversation with the patient • CA, CO: As part of informed decision, physician must state the possibility that the patient may choose to obtain the medication but not take it. • VT, CA, CO: Statute does NOT include the following: If the patient is in a long term care facility at the time the written request is made, one of the witnesses shall be an individual designated by the facility and having the qualifications specified by the Department of Human Services
10/12/2018 Page 88 63 Statutes: What Other States Have Done Differently
• CA: Attending physician shall give the patient the final attestation form, with the instruction that the form be filled out and executed by the patient within 48 hours prior to taking the medication • CA: Not liable if a person assisted the patient by preparing the medication so long as the person did not assist with the ingestion of the drug • CA: Instructs patient to keep the medication in a safe and secure location until the time that the qualified individual will ingest it • CA, WA, VT, CO: Rules for safe disposal of unused medications • CA: Actions taken in compliance with MAID statute shall not constitute neglect or elder abuse for any purpose of law • CO: An individual utilizing MAID and on Medicaid shall not have their benefits denied or altered • CA: Patient level data shall not be disclosed, discoverable, or compelled to be produced in any civil, criminal, administrative, or other proceeding • VT: Does not require statistics to be collected for public use
64 Statutes: What Other States Have Done Differently
• CA: Prohibits an insurance carrier from providing any information in communications made to an individual about the availability of an aid-in-dying drug absent a request by the individual or his or her attending physician at the behest of the individual. The bill would also prohibit any communication from containing both the denial of treatment and information as to the availability of aid-in-dying drug coverage. • DC: Death certificate states terminal disease as cause of death, but the Office of the Chief Medical Examiner shall review each death involving a qualified patient who ingests a covered medication and, if warranted by the review, may conduct an investigation. • DC: Mayor shall issue rules to specify the recommended methods by which a patient may notify first responders of his or her intent to ingest a medication; and establish training opportunities for the medical community to learn about the use of covered medications by patients, including best practices for prescribing the medication.
10/12/2018 Page 89 65
Current Data on MAID
Oregon, Washington and California statutes require that data be collected annually (as does D.C. and Colorado, but no data are available at this point)
66 Oregon MAID Utilization Rates
http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year19.pdf
10/12/2018 Page 90 67 Summary of MAID Outcomes: Oregon, 2016
Source: Oregon DWDA 2016 Data Summary
68 Washington MAID Utilization Rates
300
248 250 213 200 192 176 173 166 150 121 119 126 103 100 87 83 65 70 51 50 36
0 2009 2010 2011 2012 2013 2014 2015 2016 Participants with dispensed medications Deaths from ingestion
Data compiled from Washington’s annual DWDA data reports, 2009-2016
10/12/2018 Page 91 69 Summary of MAID Outcomes: Washington, 2016
Source: http://www.doh.wa.gov/portals/1/ Documents/Pubs/422109- DeathWithDignityAct2016.pdf
70 Summary of MAID Outcomes: California, 2016
258 individuals made a request for MAID to their physician
Note: California enacted MAID statute in 2016. As a result, all data is for 6 months, from June to December of 2016 Source: California EOLO Act 2016 Data Report
10/12/2018 Page 92 71 2016 MAID Demographics
Oregon: N=133 Washington: N=239 California: N=111 (In 6 months) SEX (Male) • Oregon: 72 (54.1%) Washington: 120 (50%) California: 51 (45.9%) AGE Oregon Washington California 18-54 8 (6.1%) 18-44 6 (3%) <60 14 (12.6%) 55-64 18 (13.5%) 45-64 65 (27%) 60-79 55 (49.5%) Note: Age categories differ for each state 65-84 83 (62.4%) 65-84 126 (53%) 80-89 29 (26.1%) 85 24 (18%) 85 42 (18%) 90 or > 13 (11.7%)
Oregon Washington California RACE / White 127 (96.2%) 232 (97%) 102(89.5%) ETHNICITY Black 0 . 3 (2.6%) Hispanic 2 (1.5%) . 3 (2.6%) Asian 2 (1.5%) . 6 (5.3%) Source: Each state’s 2016 Data Summary/Report
72 2016 MAID Demographics
Oregon: N=133 Washington: N=239 California: N=111 (In 6 months)
OR WA CA Education Less Than High School 3.8% 4% No High School Diploma 5.4% High School Graduate 17.4% 27% High School Diploma or GED 22.5% Some College 28.8% 35% Some College, No Degree 14.4% Baccalaureate or Higher 50.0% 32% Associate, Bachelor or Master Degree 45.9% Doctorate or Professional Degree 11.7%
OR WA Marital Married 47.0% 43% Widowed 19.7% 20% Status Divorced 27.3% 27% Domestic Partner . 1% Never Married/Single 6.1% 7% Source: Each state’s 2016 Data Summary/Report
10/12/2018 Page 93 73 2016 MAID Demographics
Insurance Oregon: N=133 Washington: N=239 California: N=111 (In 6 months) Oregon Washington California Private 26.3% Private Only 18% Private 18.9% Medicare, Medicaid or 61.7% Medicare, Medicaid Only 46% Medicare 44.2% Other Gov’t Combo of Private & 17% Medicaid 3.6% None 0.01% Medicare/Medicaid Medicare/Medicaid (Dual 9.0% Unknown 11.3% None <1% Eligible) Unknown 6% Medicare/Medicaid & Private 11.7% Other (Including VA) 11% Supplemental Insurance Has Insurance, but Type 9.0% Most private insurance pays for MAID medication and the physician visit Unknown By law, federal funds cannot be used for MAID medication; therefore, None 3.6% Medicare and the VA cannot pay for MAID medication Medicare enrollees may use their private supplemental insurance Medicaid can pay for MAID medication out of a pot of state-only funds Source: Each state’s 2016 Data Summary/Report
74 Underlying Illness, 2016
Oregon: N=133 Washington: N=239 California: N=111 (In 6 months)
Oregon Washington California Cancer 78.9% Cancer 77% Cancer 58.6% ALS 6.8% Neuro-degenerative 8% Neuromuscular 18% Disease (including ALS) Chronic Lower 1.5% Lung Respiratory Disease 6.3% Respiratory Disease Respiratory Disease 8% (non-cancer) (including COPD) Heart Disease 6.8% Heart Disease 8.1% Heart Disease 6% Other 6.0% Other 9% Other 2%
Source: Each state’s 2016 Data Summary/Report
10/12/2018 Page 94 75 Oregon: Underlying Illnesses (1998-2016)
MAID Deaths 90
80 Malignant Neoplasms 70 A 60 LS (Amyotrophic Lateral Sclerosis)
50 Chronic Lower Respiratory Disease
40 Heart Disease 30 HIV/AIDS 20 O 10 ther
0 2016 1998-2015
Source: Oregon DWDA 2016 Data Summary
76 Circumstances When Medication Ingested or at Death, 2016
OR WA CA Location Home 88.6% 88% . LTC/ALF/ Adult Oregon: N=133 6.8% 7% . Foster Care Washington: N=239 Hospital 2.3% 0 . California: N=111 (In 6 months) Other 2.3% 2% . Hospice Enrolled 88.7% 77% 83.8% Unknown 0 9% 4.5% Health Care Provider Present at Death (Oregon) Prescribing physician 13 (9.8%) Other provider 14 (10.5%) No provider 102 (76.7%) Unknown 4 (3.0%) Source: Each state’s 2016 Data Summary Report
10/12/2018 Page 95 MAID Patient Concerns
Oregon & Washington 2016 100 Oregon 1998-2015 77 92 90 90 Reason Provided OR % WA % Losing autonomy (%) 79 Losing Autonomy 89.5 87 80 Unable to engage in Less able to engage in activities making 89.5 84 70 enjoyable activities life enjoyable (%) Loss of dignity 65.4 66 60 Loss of dignity (%) Loss of bodily control 36.8 43 50 48 Losing control of bodily functions (%) Burden on family 48.9 51 41 40 Concern about pain 35.3 41 Burden on family, friends/caregivers (%) control 30 25 Financial implications 5.3 8 20 Inadequate pain control or concern of treatment about it (%) 10 3 Financial implications of treatment (%) 0 1998-2015 (n=991) Source: Oregon’s and Washington’s 2016 Data Summary/Report
78 What has been the impact of informing patients about end-of-life options such as hospice care and palliative care?
• In the states with available data (OR, WA, CA), the great majority of MAID users already were enrolled in hospice and had access to palliative care • Oregon: 88.7% (2016); 90.4% (1998-2015) • Washington: 77% (2016); 81% (2015); 69% (2014) • California: 83.8% (2016) • All MAID statutes require that both the attending and consulting physician inform the patient about end-of-life options, including hospice and palliative care • Hospice utilization has increased in Oregon since MAID was passed, but hospice utilization in Oregon has been among the highest in the nation since at least 19921 • In Oregon, palliative care services spending and patient satisfaction have risen since 1998, when MAID became legal2 • The request for information on MAID can lead to conversations between patients and their physicians about a range of end-of-life options2
1: Jackson A. The Inevitable—Death: Oregon’s End-of-Life Choices. Willamette Law Review, Willamette University College of Law. Salem, Oregon, 45:1(137-160) Fall 2008; 2: Cain, Cindy L. Implementing Aid in Dying in California: Experiences from Other States Indicates Need for Strong Implementation Guidance. Los Angeles, CA: UCLA Center for Health Policy Research, 2016
10/12/2018 Page 96 79 Coercion and Fraud
• Penalties for coercion and fraud included in statute: • Oregon: Class A felony • Washington: Class A felony • Vermont: Unable to find section on coercion/fraud • California: A felony • Colorado: Class 2 felony • D.C.: Class A felony • Research on instances of coercion and/or fraud is ongoing and will be presented during the final presentation
80 Estimating MAID Utilization in Virginia
Oregon: Number of MAID Deaths per 10,000 Total Deaths 45 40 38.6 37.2 35 31 30
25 21.7 22.7 19.4 20 15.2 15 12.9 12.1 10 7.4 8.1 5 0 1998-99 2000-01 2002-03 2004-05 2006-07 2008-09 2010-11 2012-13 2014 2015 2016
Data compiled from Oregon’s annual DWDA data summaries, 1998-2016
10/12/2018 Page 97 81 Estimating MAID Utilization in Virginia
• In Oregon, there were 37.2 MAID deaths per 10,000 total deaths in 2016 • Less than 1 percent of all deaths • In California the death rate was 6.06 per 10,000 total deaths for the first six months after enactment (June-December, 2016) • Out of 191 prescriptions written, the outcome for 59 patients is still unknown • For Oregon and Washington (states for which there is trend data), the number of people who died due to MAID medication has remained below 200 individuals • Estimate for Virginia: Like Oregon and Washington, it is likely that the number of people requesting MAID would be quite small for the first few years, gradually increasing to approximately 242 individuals dying from MAID medications • Oregon: 37.2 / 10,000 = .00372 percent of all deaths • Virginia: .00372 x 65,000 (total deaths in 2015*) = 241.8
*Most recent data. Sources: Oregon, Washington and California data summaries/reports; and for Virginia death data: http://vaperforms.virginia.gov/indicators/healthfamily/mortalityLongevity.php
82
Joint Commission on Health Care Street Address Mailing Address Telephone 600 E. Main Street PO Box 1322 804.786.5445 Suite 301 Richmond, VA Fax Richmond, VA 23219 23218 804.786.5538 http://jchc.virginia.gov
10/12/2018 Page 98 83
References (in bold) and Bibliography
• American Academy of Actuaries. (2017). End-of-life care in an aging world: A global perspective. American Academy of 84 Actuaries, 1-10. • Anguiano, L., et al. (2012). A Literature Review of Suicide in Cancer Patients. Cancer Nursing, 35(4), E14-E26. • Balch, B. (2017). Death by lethal prescription: A right for older people or their duty? Generations- Journal of the American Society on Aging, 41(1), 42-46. • Bharucha, A. J. et al. (2003). The pursuit of physician-assisted suicide role of psychiatric factors. Journal of Palliative Medicine, 6(6), 873-883. • Blanke, C. et al. (2017). Characterizing 18 years of the Death with Dignity Act in Oregon. JAMA Oncology, 243, E1-E4. • Breitbart, W. et al. (2000). Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. JAMA, 284(22), 2907-2911. • British Medical Association. (2016, January). End-of-Life care and physician-assisted dying: 1. Setting the scene. London: BMA House. • British Medical Association. (2016). End-of-Life care and physician-assisted dying: 2. Public dialogue research. London: BMA House. • Cain, C. L. (2016). Implementing Aid in Dying in California: Experiences from Other States Indicates Need for Strong Implementation Guidance. Los Angeles, California: UCLA Center for Health Policy Research. • Campbell, C. S., & Black, M. A. (2014). Dignity, death and dilemmas: A study of Washington hospices and physician- assisted death. Journal of Pain and Symptom Management, 47(1), 137-153. • Campbell, C. S., & Cox, J. C. (2012). Hospice-assisted death? A study of Oregon hospices on Death with Dignity. American Journal of Hospice & Palliative Medicine, 29(3), 227-235. • Chochinov, H. M. et al. (1995). Desire for death in the terminally ill. Am J Psychiatry, 152(8), 1185-1191. • Clymin, J. et al. (2012). Washington state Death with Dignity Act. Journal of Hospice & Palliative Nursing, 14(2), 141-148. • Craig, A. et al. (2007). Attitudes toward physician-assisted suicide among physicians in Vermont. Journal of Medical Ethics, 33(7), 400-403.
10/12/2018 Page 99 • Critser, S. E. (2018). National Standards and State Variation in Physician Orders for Life-Sustaining Treatment Forms. 85 JOURNAL OF PALLIATIVE MEDICINE, 21(7), 978-986. • Dobscha, S. et, al. (2004). Oregon Physicians' Responses to Requests for Assisted Suicide: A Qualitative Study. Journal of Palliative Medicine, 7(3), 451-461. • Dore, M. K. (2010). "Death with Dignity": A recipe for elder abuse and homicide (Albeit not by name). Marquette Elder's Advisor, 11(2), 386-401. • Drachsler, D. A. (2013, July 10). Suicide and the Law in Virginia. ACLU of Virginia. Retrieved from https://acluva.org/en/news/suicide-and-law-virginia • Drum, C. E. et al. (2010). The Oregon Death with Dignity Act: Results of a literature review and naturalistic inquiry. Disablity and Health Journal, 3, 3-15. • Emanuel, E. J., & Battin, M. P. (1998). What are the potential cost savings from legalizing physician-assisted suicide? The New England Journal of Medicine, 339(3), 167-172. • Foley, H. H. (2008). Physician-assisted suicide in Oregon: a medical perspective. Michigan law review, 1613-1639. • Fromme, E. et al. (2004). Increased family reports of distress or dying Oregonians 1996 to 2002. Journal of Palliative Medicine, 7(3), 431-442. • Fulton, J. et al. (2018). Psychotherapy Targeting Depression and Anxiety for Use in Palliative Care: A Meta-Analysis. Palliative Care Review, 21(7), 1024-1037. • Ganzini. (2000, February 24). Physicians’ Experiences with Oregon Death With Dignity Act. New England Journal of Medicine, 342(8), 557-563. • Ganzini, L., & Dobscha, S. K. (2003). If it isn't depression... Journal of Palliative Medicine, 6(6), 927-930. • Ganzini, L. et al. (2001). Oregon physicians' attitudes about and experiences with end-of-life care since passage of the Oregon Death with Dignity Act. JAMA, 285(18), 2363-2369. • Ganzini, L. et al. (2017). Physician's experiences with the Oregon Death with Dignity Act. The New England Journal of Medicine, 342(8), 557-563.
• Ganzini, L., Goy, E. R., & Dobscha, S. (2009, March 9). Oregonians' reasons for requesting physician aid in dying. Retrieved 86 from Arch Intern Med: www.archinternmed.com • Harkness, K. (2018, February 21). Doctor: Insurance wouldn't pay for patients' treatments, but offered assisted suicide. Retrieved from Daily Signal: http://dailysignal.com • Harman, S., & Magnus, D. (2017, July). Early Experience with the California End of Life Act. Health Care Policy and Law, 177(7), 907-908. • Hastings Center. (2018, January 4). Physician-Assisted Death: Ethical Debates, Professional Challenges, Societal Questions. Retrieved from https://www.thehastingscenter.org/category/end-of-life/ • Hedberg, K., & Tolle, S. (2009). Putting Oregon's Death with Dignity Act in perspective: Characteristics of decedents who did not participate. The Journal of Clinical Ethics, 20(2), 133-135. • Hickman, S., & Critser, R. (2018). National Standards and State Variation iin Physician Orders for Life-Sustaining Treatment Forms. Journal of Palliative Medicine, 21(7), 978-986. • Hudson, P. L. et al. (2006). Desire for hastened death in patients with advanced disease and the evidence base of clinical guidelines: A systematic review. Palliative Medicine, 20, 693-701. • Jackson, A. (2008, Fall). The Inevitable—Death: Oregon’s End-of-Life Choices. Willamette Law Review, 45(1), 137-160. • Kimbell, B. et al. (2015). Managing uncertainty in advanced liver disease: A qualitative mulitiperspective, serial interview study. British Medical Journal, 1-23. • Kimbell, B. et al. (2016, July 18). Embracing inherent uncertainty in advanced illness. Retrieved from BMJ British Medical Journal: bmj.i3802 • Lee, B. C. (2014). Oregon's experience with aid in dying: findings from the death with dignity laboratory. Annals of the New York Academy of Science, 0077(8923), 1-7. • LiPuma, S. H., & DeMarco, J. P. (2016). Palliative care and patient autonomy: Moving beyond prohibitions against hastening death. Health Services Insights, 9, 37-42. • Loggers, E. T. et al. (2013). Implementing a death with dignity program at a comprehensive cancer center. The New England Journal of Medicine, 368(15), 1417-1424.
10/12/2018 Page 100 • Meghani, S. H., & Hinds, P. S. (2014, December 11). Policy brief: The Institute of Medicine report Dying in 87 America: Improving quality and honring individual preferences near the end of life. Retrieved from Science Direct: www.science direct.com • Miller, L. L. et al. (2004). Attitudes and experiences of Oregon hospice nurses and social workers regarding assisted suicide. Palliative Medicine, 18, 685-691. • Monforte-Royo, C., Sales, J. P., & Balaguer, A. (2016). The wish to hasten death: Reflections from practice and research. Nursing Ethics, 23(5), 587-589. • Mystakidou, K. et al. (2005, February 22). Desire for death near the end of life: the role of depression, anxiety and pain. Retrieved from Science Direct: www.sciencedirect.com • Nguyen, H. Q. et al. (2017, December 26). Characterizing Kaiser Permanente Southern California’s ExperienceWith the California End of Life Option Act in the First Year of Implementation: Research Letter. Journal of American Medical Association Internal Medicine, E1-E5. • NIH National Cancer Institute. (2017, May 2). Depression (PDQ)- Health Professional Version. Retrieved from National Cancer Institute: https://www.cancer.gov • Norton, E. M., & Miller, P. J. (2012). What their terms of living and dying might be: Hospice social workers discuss Oregon's Death with Dignity Act. Journal of Social Work in End-of-Life & Palliative Care, 8, 249-264. • O'Connell, H. et al. (2004). Recent developments: Suicide in older people. British Medical Journal, 329, 895- 899. • O'Mahony, S. et al. (2005). Desire for hastened death, cancer pain and depression: Report of a longitudinal observational study. Journal of Pain and Symptom Management, 29(5), 446-457. • Orentlicher, D. et al. (2016). Clinical criteria for physican aid in dying. Journal of Pallative Medicine, 19(3), 259-263. • Patients Right Council. (1998, January). Prescription death: Oregon struggles to implement new law. Retrieved from Patients Right Council: http://patientsrightcouncil.org/site/update012
• Peled, H. et al. (2017). Enhancing informed consent for physician aid in dying: Potential role of handout on possible 88 benefits of palliative care. Journal of Oncology Practice, 13(10), e838-e842. • Pestinger, M. et al. (2015). The desire to hasten death: Using Grounded Theory for a better understanding "When perception of time tends to be a slippery slope". Palliative Medicine, 29(8), 711-719. • Pope, T. M. (2017). Legal History of Medical Aid in Dying: Physician Assisted Death in the U.S. Courts and Legislatures. New Mexico Law Review, forthcoming special symposium issue. • Rodin, G., et al. (2007). The desire for hastened death in patients with metastic cancer. Journal of Pain and Symptom Management, 33(6), 661-675. • Rodriguez-Prat, A. et al. (2016, March 24). Patient perspectives of dignity, autonomy, and control at the end of life: Systematic review and meta-ethnography. Retrieved from Plos one: journal.pone.0151435 • Rogers, B. (2018, February 26). Virginia earns a "B" on report card for access to palliative care. Retrieved from VCHI Virginia Center for Health Innovation: http://innovatevirginia.org • Rose, T. F. (2007). Physician-assisted suicide: development, status, and nursing perspectives. journal of nursing law, 11(3), 141-151. • Rosenfeld, B. et al. (2014, March 28). Does desire for hastened death change in terminally ill cancer patients? Retrieved from Science Direct: www.elsevier.com/lcate/socscimed • Russell, J. A., & Dulay, M. F. (2016). Hastened death in ALS. Neurology, 87, 1312-1313. • Seattle Cancer Care Alliance. (2012). Death with Dignity. Seattle Cancer Care Alliance. • Simon, R., Levenson, J., & Shuman, D. (2005). On Sound and Unsound Mind: The Role of Suicide in Tort and Insurance Litigation. Journal of American Academy of Psychiatry Law, 33(2), 176-182. • Sinuff, T. et al. (2015). Improving end-of-life communication and decision making: The development of a conceptual framework and quality indicators. Journal of Pain and Symptom Management, 49(6), 1070-1080.
10/12/2018 Page 101 • Smith, K. A. et, al. (2015). Predictors of pursuit of physician-assisted death. Journal of Pain and Symptom 89 Management, 49(3), 555-561. • Stevinson, C. et, al. (2010). Defining priorities in prognostication research: results of a consensus workshop. Palliative Medicine, 24(5), 462-468. • Sullivan, M. D., & Youngner, S. J. (1994). Depression, competence, and the right to refuse lifesaving medical treatment. Am J Psychiatry, 151(7). • Voaklander, D. C. et al. (2017, August 30). Medical illness, medication use and suicide in seniors: a population- based case-control study. Retrieved from BMJ British Medical Journal: http://jech.bmj.com • Waldrop, D. P. et al. (2018). Mediating Systems of Care: Emergency Calls to Long-Term Care Facilities at Life’s End. JOURNAL OF PALLIATIVE MEDICINE, 21(7), 987-991. • Waldrop, D., & Meeker, M. A. (2012, August 28). Communication and advanced care planning in palliative and end-of-life care. Retrieved from Science Direct: www.sciencedirect.com • Waldrop, D., McGinley, J., & Clemency, B. (2018). Mediating systems of care: Emergency calls to long-term care facilities at life's end. Journal of Palliative Medicine, 21(7), 987-991. • Wang, S.-Y. et al. (2015). Geographic variation of hospice use patterns at the end of life. Journal of Palliative Medicine, 18(9), 771-781. • Wilson, K. et al. (200, Septemeber 11). Attitudes of terminally ill patients toward euthanasia and physician- assisted suicide. Retrieved from Arch Intern Med: www.archinternmed.com
90
Joint Commission on Health Care Street Address Mailing Address Telephone 600 E. Main Street PO Box 1322 804.786.5445 Suite 301 Richmond, VA Fax Richmond, VA 23219 23218 804.786.5538 http://jchc.virginia.gov
10/12/2018 Page 102 18-201 Truth in Advertising
Submitted by Virginia Society of Plastic Surgery
WHEREAS, survival in the modern marketplace requires promotion of a physician’s practice and credentials in various advertising media, and
WHEREAS, most practitioners do so ethically, there is currently a loophole in Virginia’s regulations that can be exploited, and
WHEREAS, Virginia’s regulations require disclosure of the name of the specialty board, but does not specify that that such a board must be a legitimate educational body, and
WHEREAS, healthcare consumers may not be able to distinguish between legitimate boards and less reputable organizations thereby devaluing the term board-certified to Virginia patients seeking an adequately trained and qualified physician, and
WHEREAS, boards with lower standards may pose a risk to patient safety in the Commonwealth, and
WHEREAS, there is a national coalition concerned about this issue comprised of the American Medical Association, American Academy of Dermatology Association, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology – Head and Neck Surgery, American College of Emergency Physicians, American Osteopathic Association, American Society for Dermatologic Surgery Association, and American Society of Plastic Surgeons, therefore be it
RESOLVED, the Medical Society of Virginia supports specifying that “board-certified” must refer to an American Board of Medical Specialties (ABMS), American Osteopathic Association Board Certification (AOA), or other boards that maintain similarly high standards of certification.
10/12/2018 Page 103 Staff Analysis – Resolution 18-201: Truth in Advertising. Submitted by the Virginia Society of Plastic Surgery
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients Virginia law requires physicians Raise the value - Use of Title Benefits: Staff recommends adopting this to disclose the name of the 05.6.02 of physicians “Dr.” Physicians board-certified resolution. specialty board, but does not The Medical Society of by a board with high specify that such a board must Virginia supports the standards will gain While this may remove the ability of be a legitimate educational body enforcement by increased value from some physicians to use the term appropriate state agencies their certification “board-certified” it is important to Patients likely cannot distinguish of the statutes requiring the ensure that physicians hold between boards with high disclosure of degree Patients will be better themselves to the highest quality standards and less reputable earned when using prefix able to distinguish standard and define the standards for organizations “Dr.” for advertising between differing comparison in the future. purposes. physician qualifications, By allowing physicians certified which may improve Virginia Society of Plastic Surgery, by both high- and low-standard patient outcomes and MSV, and others would be able to boards to claim the term “board safety work cooperatively to enact this certified,” the term “board- change in Virginia. certified” becomes devalued Drawbacks: The resolution asks MSV to Some physicians will lose support the use of the term their ability to use the “board-certified” only for the term “board-certified,” if American Board of Medical their board does not meet Specialties (ABMS), American the standard defined in Osteopathic Association Board the resolution Certification (AOA), or other boards that maintain similarly high standards of certification in advertising.
10/12/2018 Page 104 18-202
Remove Restrictive Covenants for Healthcare Providers in Virginia
Submitted by: Richmond Academy of Medicine
WHEREAS, restrictive covenants are often found in employment contracts when a physician joins a medical practice, and
WHEREAS, the covenant can include non-compete, non-solicitation, and confidentiality agreements, and
WHEREAS, a non-compete clause typically prohibits a physician from competing against the former practice within a region for a specified duration of time after separation from the originating practice, and
WHEREAS, a non-solicitation clause typically delineates a specified time period during which the physician cannot solicit patients or employees from the originating practice, and
WHEREAS, confidentiality agreements are typically indefinite and restrict the physician from sharing practice or specific trade secrets, and
WHEREAS, restrictive covenants may protect business interest of the originating practice by limiting competition, it may result in undue hardship for the physician and limit valuable medical expertise access to the public, and
WHEREAS, covenants to non-compete limit competition, disrupt continuity of care between physicians and patients, and limit overall access, and
WHEREAS, non-competes may restrict the physician’s right to practice medicine for a specified time in a region, and
WHEREAS, non-competes do not take into consideration the patient’s right to choose their individual physician, and
WHEREAS, physicians are to practice medicine in the best interest of their patients, safeguarding confidences and privacy, and
WHEREAS, physicians, with the exception of emergencies, should be free to choose for whom to care, with whom to associate, and in which environment to best practice medicine, and
WHEREAS, restrictive covenant, non-compete agreements deter physician applicants, forces physicians to stay in undesirable practice environments, forces physicians to leave a region, and thereby, may devoid a region of access, medical expertise, and continuity of care, and restricts competition which will only enhance the quality of care and service, as well as drive down health care costs, and
WHEREAS, a superior example of successful state legislation to remove restrictive covenants was enacted by the State of New Mexico in 2015 and is attached hereto as supporting documentation, and
RESOLVED, that the Medical Society of Virginia conduct a study to evaluate and consider the impact of Restrictive Covenant agreements for healthcare providers and how it impacts patient access in Virginia. This study shall include evaluation of other states where elimination of
10/12/2018 Page 105 Restrictive Covenant agreements has been successful. Further, a report of findings shall be provided to members by December 31, 2019.
10/12/2018 Page 106 Staff Analysis – Resolution 18-202: Remove Restrictive Covenants for Healthcare Providers in Virginia Submitted by Richmond Academy of Medicine
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
Empower 10.3.06- Freedom of Benefits: Staff recommends this resolution be Physicians may encounter different physicians to Choice - Patients and referred to the Board of Directors for legal agreements as a condition of manage Physicians Would provide flexibility action. their employment that limits their change for physicians to more ability to seek future employment, Date: 11/5/1994 freely practice medicine maintain a patient relationship, or Strengthen the The Medical Society of and deliver patient care. Physician employment practices are open/move to a new practice. value of MSV Virginia opposes any valuable topics for the MSV to engage legislative program which May increase access to in review. However, it is likely that a These conditions may be non- would prevent free choice care in Virginia. study of this nature may incur costs compete clauses, non-solicitation of physician by patient or and may shift the organization’s clauses, a prohibition on practice in a patient by physician. established 2019 priorities given the particular region and/or type of Reaffirmed 11/7/2004 Drawbacks: included timeline. As such, the Board medicine. Reaffirmed 10/26/2014 should evaluate cost and May cause financial loss organizational capacity to determine These agreements may limit a for practices that invest in when such a study could occur. physician’s ability to practice and a physician, who patient’s ability to seek care. ultimately leaves the practice. These agreements may be beneficial for a physician practice or other setting to ensure the practice is able to recruit and retain physicians for a period of time, whereby the practice could realize return on any investments made into the education/training of a new provider.
MA, DE, CO, and RI have enacted statutes that do not allow non- competes to be enforced against physicians. Other states have limited what covenants are allowed to restrict.i
This resolution asks MSV to conduct a study to evaluate and consider the impact of Restrictive Covenant agreements for healthcare providers and how it impacts patient access in
10/12/2018 Page 107 Virginia by Dec. 31, 2019.
i https://www.natlawreview.com/article/non-compete-laws-affecting-health-care-professionals-various-us-jurisdictions
10/12/2018 Page 108 18-203
Certificate of Public Need (COPN) Reform
Submitted by: Daniel R. Cavazos, M.D
WHEREAS, the COPN has encumbered competition in the Commonwealth’s health care market and prevented decreased health care costs to the citizens of the Commonwealth, therefore be it
RESOLVED, that the MSV strongly support the reform of the Commonwealth’s COPN law to allow for the establishment of private medical facilities to increase treatment options which would lower health care costs and increase access to all health care consumers.
10/12/2018 Page 109 Staff Analysis – Resolution 18-203: Certificate of Public Need (COPN) Reform
Submitted by Daniel R. Cavazos, M.D
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
Empower 30.4.04- MSV COPN Benefits: Staff recommends this resolution be
physicians to Policy not adopted and policy 30.4.04 be Certificate of Public Need is a manage Date: 1/20/2016 Reform of COPN reaffirmed. program that operates within Virginia change The Medical Society of program may increase and requires individuals seek Virginia supports the access and lower costs This resolution calls for MSV support approval from the State Health deregulation of COPN. The for patients. of COPN reform, which is captured Commissioner prior to initiating Medical Society of Virginia within existing policy. MSV has projects such as general acute care will consider supporting engaged in legislative and regulatory services, perinatal services, Program is often individual COPN legislation action on COPN as a top priority for diagnostic imaging services, cardiac considered cumbersome on a case-by case-basis, several years and continues to support services, general surgical services, and difficult to navigate. with decision for approval efforts to reform the program, while organ transplantation services, derived from previously maintaining patient safety and quality medical rehabilitation services, adopted principles of requirements. psychiatric/substance abuse Drawbacks: patient safety and access services, mental retardation services, to quality, affordable health lithotripsy services, miscellaneous Complete deregulation of care. The Medical Society capital expenditures and nursing COPN is controversial of Virginia continues to facility services. support the economic
viability of Virginia's MSV has supported COPN reform, academic health centers. while maintaining support for patient Newly deregulated safety and access to quality, services should be affordable health care, the economic required to meet a charity viability of Virginia's academic health care commitment as well centers, and charity care. as recognized standards of
accreditation or quality. This resolution asks MSV to support Reaffirmed 5/6/2017 reform of the COPN law.
10/12/2018 Page 110 18-204
Resolution to Study the Makeup of Our State Government for the Purpose of Creating an Entity to Deliver Healthcare
Submitted by: Monroe G. Baldwin, Jr., M. D.
WHEREAS, only physicians/doctors are responsible for healthcare delivery, and
WHEREAS, physicians/doctors are licensed to deliver healthcare by our state, and
WHEREAS, the Profession of Medicine/Medical Society of Virginia is a pillar of state society in search of a proper structure to carry out its responsibilities, and
WHEREAS, today healthcare is delivered in a free-market economy stimulating the profit drive to pay for offices, family and retirement, and
WHEREAS, doctors and hospitals move towards paying patients while the preponderance of illness is in the lower socioeconomic population.
WHEREAS, the supply demand curve, automatically operational in a free market guarantees that within time prices(healthcare plans) will rise above the affordability of lower socioeconomic working people violating the profession of medicine's time honored custom to not ask more than a patient can pay, and
WHEREAS, there are gross inequities in pay between specialties and primary care rendering it harder to draw people into primary care, the bedrock of medical delivery, and
WHEREAS, the Medical Society of Virginia needs a statistical system to alert doctors on where the stand with regard to their peers on laboratory use, number of patients seen/day, progress in designated goals such as diminishing obesity, venereal disease, deaths before age 5, as well as comparing our state with other industrialized countries, and
WHEREAS, an entity representing all doctors/physicians in the State of Virginia could collect funds from the federal government, State of Virginia, and commercial insurers; and pay the doctors appropriately, and place them in areas of medical need, therefore be it
RESOLVED, that the Medical Society of Virginia study the makeup of our state government in order to present a plan for an entity managed by doctor/physicians to be responsible for healthcare, pay doctors/physicians appropriately, keep necessary statistics, and place doctors where they are needed.
10/12/2018 Page 111 Resolution 18-204: Resolution to Study the Makeup of Our State Government for the Purpose of Creating an Entity to Deliver Healthcare Submitted by Monroe G. Baldwin, Jr., M. D.
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients Many low income patients Benefits: Staff recommends not adopting this without insurance in Virginia lack N/A resolution. access to healthcare providers 10.3.08- Free-Market Some patients would Date: 11/5/1994 The have increased access to MSV’s existing policy does not support Many geographic areas are Medical Society of Virginia care efforts to move health care deliveryand experiencing a shortage of endorses a plurality of financing systems away from thefree healthcare providers health care delivery and Drawbacks: market setting financing systems in a free
Socioeconomic status and market setting. Physicians would Previously considered in past House of geographic location should not Reaffirmed 11/7/2004 experience limited choice Delegates sessions and has not determine level and quality of Reaffirmed 10/26/2014 in specialty, practice type, advanced. care geographic location, and The challenges facing health care and fees physicians in Virginia are better suited Virginia should ensure that all patients have access to care by to be addressed through collaborative May affect negatively the creating an entity that controls efforts that include participation from profession’s appeal to the the healthcare market by: all relevant stakeholders. next generation and o Collecting physician escalate the physician charges from federal and shortage state governments and
commercial carriers to Overhauling the existing pay physicians properly healthcare system to a o Place physicians state-controlled model geographically would likely create
barriers to patient care Create a physician-run medical monitoring system that educates doctors to improve practice
This resolution asks MSV to study state government and present a plan for an entity, managed by physicians, that is responsible for the delivery of healthcare.
10/12/2018 Page 112 18-205
Resolution to Declare Abortion and Euthanasia Veterinarian Procedures
Submitted by: Monroe G. Baldwin, Jr., M. D.
WHEREAS, the essence of medical care is nurturing and healing a patient, community, or society forming a dynamic foundation that launches individuals into the profession to become clinicians, teachers, and researchers, and
WHEREAS, when human life is involved, killing and nurturing are diametrically opposed, and
WHEREAS, taking human life is not nurturing no matter how many problems it solves, and
WHEREAS, each individual doctor/physician has free will but the profession of medicine must always maintain principles and standards, and
WHEREAS, taking life indicates to the physician that some life is less important than other life such as providing less quality health care to those without adequate funds, and
WHEREAS, veterinarians routinely care for all living animals, fowl, and fish except for human beings commonly taking lives to prevent spread of contagion and to prevent suffering as well as performing abortion, and
WHEREAS, human beings are primates and therefore may have their lives taken by veterinarians as is common in that profession, and
WHEREAS, having veterinarians perform abortion and euthanasia allows physicians to take the time honored Hippocratic Oath without exceptions which weaken it, therefore be it
RESOLVED, that abortion and euthanasia are veterinarian procedures.
10/12/2018 Page 113 Staff Analysis – Resolution 18-205: Resolution to Declare Abortion and Euthanasia Veterinarian Procedures
Submitted by Monroe G. Baldwin, Jr., M. D.
Strategic Impact on Background Plan MSV Policy Staff Recommendation Physicians/Patients (RISE)
N/A 25.2.04- Physician Assisted Suicide and Euthanasia Benefits: Staff recommends this This resolution asks Date: 11/8/1997 Reaffirmed 10/28/2007, 10/22/2017 resolution be not adopted. MSV to support In dealing with the terminally ill, suffering patient, physicians may N/A classifying abortion ethically: The Medical Society of and medical aid in 1. Withdraw life-prolonging procedures or decline to initiate such Virginia does not have dying/physician treatment in situations in which a patient is terminally ill and has given Drawbacks: jurisdiction over what assisted dying as informed consent for this to be done either personally or through an procedures are classified veterinary advance directive, or in instances in which the patient is unable to give as veterinary medicine. procedures. such consent it is obtained from an authorized family member or a N/A surrogate.
2. Prescribe medication to a patient even though the potential exists for inappropriate use by the patient that may result in death, provided the physician’s intent in prescribing such medication is not to cause death or to assist the patient in committing suicide. 3. In situations where the distinction between relieving suffering and causing a terminally ill patient’s death may be blurred, the physician should exercise his/her best medical judgment in caring for the patient. 4. Withhold or withdraw treatment from a terminally ill patient that the physician reasonably believes to be futile either in terms of promoting or improving the health of the patient or alleviating the patient’s suffering, provided the physician’s purpose in so doing is not actively to cause the patient’s death, but rather to allow death to occur with minimal suffering. In accordance with the above statements (which are consistent with and supplemented by the views of the Council on Ethical and Judicial Affairs of the American Medical Association 2.17, 2.20 and 2.21), the Medical Society of Virginia strongly opposes the practice of physician assisted suicide or euthanasia.
25.1.01 – Opposition to Title X Prohibition on Abortion Counseling or Referral Date: 11/9/1991 The Medical Society of Virginia opposes Title X regulations that prohibit counseling or referral for abortion services and prohibit any discussion of abortion between the physician and the patient. The Medical Society of Virginia urges federal legislation or executive action to overturn or rescind such regulations. Reaffirmed 10/30/2011
10/12/2018 Page 114 18-206
Opposing Work Requirements for Virginia Medicaid Eligibility
Submitted by: Virginia Chapter of the American College of Physicians
WHEREAS, the State of Virginia made a positive step towards improving healthcare access by passing Medicaid Expansion in May 2018, and
WHEREAS, eligibility, though, for non-disabled adults requires that they are either working, in school, or participating in other community engagement activities, and
WHEREAS, such requirements pose an undue burden on patients who may be unable to find work or the equivalent, or document an exemption or disability, and
WHEREAS, such work requirements also pose a burden to physicians who will be in a position to adjudicate whether or not their patients are considered disabled, and
WHEREAS, work requirements in effect decrease overall participation in Medicaid, leaving patients without access to necessary healthcare, therefore be it
RESOLVED, that the Medical Society of Virginia promote legislation to oppose work requirements as a condition of eligibility for Medicaid.
10/12/2018 Page 115 Staff Analysis – Resolution 18-206: Opposing Work Requirements for Virginia Medicaid Eligibility Submitted by the Virginia Chapter of the American College of Physicians
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
Empower physicians 10.6.07- Expand Medicaid under Benefits: Given the complex nature Medicaid expansion passed in a to manage change the ACA and implications of special session in 2018; the Date: 11/2/2012 Work requirements adopting a position that Commonwealth is currently working to The Medical Society of Virginia may promote fiscal would cause the implement the new law. supports legislation to fully expand responsibility and organization to oppose
Medicaid under the limits set by lower costs Medicaid expansion, if it is As part of expansion, Virginia law the ACA with two conditions: 1) the will of the House to includes work requirements. These that any expansion be fiscally take additional action, the requirements do contain exemptions Patients with severe responsible; and 2) that such discussion and for children under the age of 18 or diseases/diagnosis expansion reimburse physicians implications of adoption individuals under the age of 19 who that prevent them from for provision of professional should be continued with are participating in secondary working, may be services to Medicaid patients at a the MSV Board of education; individuals age 65 years exempt from these rate that assures access to care Directors and AMA and older; individuals who qualify for requirements for Medicaid patients. Delegation to better medical assistance services due to Reaffirmed 10/22/2017 understand the blindness or disability, including implications for the individuals who receive services Drawbacks: Society. pursuant to a § 1915 waiver;
individuals residing in institutions; Work requirements If the House would like to individuals determined to be medically may prevent otherwise adopt policy that opposes frail; individuals diagnosed with serious eligible individuals work requirements, staff mental illness; pregnant and from securing health suggests the following postpartum women; former foster care amendments to ensure the children under the age of 26; policy represents a individuals who are the primary Currently, work position that is evergreen. caregiver for a dependent, including a requirements are part
dependent child or adult dependent of Virginia’s approved RESOLVED, that the with a disability; and individuals who Medicaid expansion Medical Society of Virginia already meet the work requirements of package promote legislation to the TANF or SNAP programs. oppose work requirements
as a condition of eligibility The AMA currently opposes work for Medicaid. requirements as criteria for Medicaid coveragei.
This resolution asks MSV to oppose work requirements as a condition of eligibility for Medicaid coverage.
10/12/2018 Page 116 i Opposition to Medicaid Work Requirements H-290.961. https://policysearch.ama-assn.org/policyfinder/detail/work%20requirement%20medicaid?uri=%2FAMADoc%2FHOD.xml-H-290.961.xml
10/12/2018 Page 117
February 22, 2018
Seema Verma Administrator Centers for Medicare and Medicaid Services 7500 Security Boulevard Baltimore, MD 21244
Re: Mississippi Medicaid Workforce Training Initiative 1115 Demonstration Waiver Application
Dear Administrator Verma:
The American College of Physicians appreciates this opportunity to comment on the Mississippi Medicaid Workforce Training Initiative 1115 Demonstration Waiver Application. The American College of Physicians is the largest medical specialty organization and the second largest physician group in the United States, representing 152,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness.
The Mississippi Department of Medicaid seeks to require non-disabled adults, including parents, caretakers and Transitional Medical Assistance enrollees, to participate in workforce training, volunteering, Office of Employment Security programs, or other activities to qualify for or maintain Medicaid coverage. Exempted populations include children under the age of 19 and pregnant women. Other members exempt from the workforce training or work requirement include individuals diagnosed with a mental illness, participating in an alcohol or other drug abuse treatment program, and those physically or mentally unable to work. Eligible individuals who do not meet the work or training requirements will lose eligibility on the first day of the month after non-compliance is determined. Those who lose eligibility may reenroll upon future compliance with the requirements.
ACP policy states that work-related or job search activities should not be a condition of eligibility for Medicaid. Assistance in obtaining employment, such as through voluntary enrollment in skills- and interview-training programs, can appropriately be made available provided that it is not a requirement for Medicaid eligibility. Work or community engagement status should not be a condition of Medicaid eligibility for a variety of reasons. According to the Kaiser Family Foundation, 60% of nonelderly adults are already working and 8 in 10 live in families with at least one person employed (i). Those who are not working often have a valid reason; they may be taking care of a loved one, going to school, unable to find employment, or are sick or disabled.
10/12/2018 Page 118
A research letter surveying people enrolled in Michigan’s Medicaid expansion program, the Healthy Michigan Plan, found that enrollees were “more likely to report being unable to work if they were older, male, or in fair or poor health or had chronic health conditions or functional limitations”(ii). One survey found that 55% of people who were unemployed reported that enrolling in Medicaid enabled them to search for a job and those who were working said they were able to do their job better after they gained coverage (iii). A study of Ohio Medicaid enrollees found that about 75% of unemployed people who were searching for a job reported that Medicaid coverage made it easier to search for employment and 52% of those currently employed said the coverage enabled them to continue working (iv). If the sick and disabled are disenrolled from Medicaid, they will lose the health insurance that could empower them to work and further their engagement in the community.
Work requirements will impose an unnecessary and unjustified burden on patients to document that they are eligible for an exemption and an unnecessary and unjustified burden on physicians who may be asked to attest that their patients have an exempted medical condition. For patients, work requirements will place an onerous reporting burden that may cause them to delay or forego care or leave the program altogether. Evidence shows that when Medicaid and other programs add paperwork and other administrative requirements, enrollees are less likely to participate (v,vi,vii). ACP greatly appreciates CMS’ initiative to reduce administrative burdens through its Patients Over Paperwork initiative, but work requirements could add substantial paperwork hassles that will reduce the amount of time physicians have to care for their patients. Further, work requirements may force physicians to make a choice between compromising their professional integrity and causing their patients to lose health coverage if a patient seeks a disability assessment to become exempt from the work requirement.
The state may have to make a substantial financial investment in systems to track work requirement compliance. The TANF program provides historical context. According to the Medicaid and CHIP Payment and Access Commission, “monitoring beneficiary compliance with [TANF] work requirements has been complex for states, requiring significant staff time and coordination across agencies and with employers” (viii). We believe that limited Medicaid dollars are best used to improve patient health outcomes, not to create wasteful bureaucratic administrative systems.
Under the proposal, work requirements will be imposed on parents and caretakers with incomes up to 27% of the federal poverty level. This is a concern because even if Medicaid enrollees do find employment, their increased income may make them ineligible for Medicaid and their new employer may not offer affordable health insurance, increasing the risk of losing insurance. An evaluation of TANF recipients who entered the workforce found that only one-third received health coverage through their employer (viii).
Most importantly, work requirements are inconsistent with the purpose of the Medicaid program because they impose harmful and unnecessary eligibility conditions and administrative burdens that will result in many of the most vulnerable Mississippians losing coverage. We know that uninsurance is
2
10/12/2018 Page 119 associated with increases in mortality (ix). Any policy that reverses the gains in health and well-being from being insured is unacceptable.
ACP appreciates your consideration of our comments. If you have any questions please contact Ryan Crowley, Senior Associate for Health Policy at [email protected].
Sincerely,
Jack Ende, MD, MACP President
i Garfield R, Rudowitz R, and Damico A. Understanding the Intersection of Medicaid and Work. Kaiser Family Foundation. January 2018. ii Tipirneri R, Goold SD, Ayanian JZ. Employment Status and Health Characteristics of Adults with Expanded Medicaid Coverage in Michigan. JAMA. 2017;doi:10.1001/jamainternmed.2017.7055 iii University of Michigan Institute for Healthcare Policy and Innovation. Medicaid Expansion Helped Enrollees Do Better at Work or in Job Searches. July 27, 2017. Accessed at http://ihpi.umich.edu/news/medicaid-expansion- helped-enrollees-do-better-work-or-job-searches iv Ohio Department of Medicaid. Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly. v Herd P. How Administrative Burdens Are Preventing Access to Critical Income Supports for Older Adults: The Case of the Supplemental Nutrition Assistance Program. Public Policy and Aging Report. 2015;25:52-55. vi U.S. Government Accountability Office. Medicaid: States Reported That Citizenship Documentation Requirement Resulted in Enrollment Declines for Eligible Citizens and Posed Administrative Burdens. 2006. Accessed at https://www.gao.gov/assets/270/263053.pdf vii Sanger-Katz M. Hate Paperwork? Medicaid Recipients Will Be Drowning in It. New York Times. January 18, 2018. Accessed at https://www.nytimes.com/2018/01/18/upshot/medicaid-enrollment-obstacles-kentucky-work- requirement.html viii Medicaid and CHIP Payment and Access Commission. Work as a Condition of Medicaid Eligibility: Key Take- Aways from TANF. October 2017. Accessed at https://www.macpac.gov/wp-content/uploads/2017/10/Work-as-a- Condition-of-Medicaid-Eligibility-Key-Take-Aways-from-TANF.pdf ix Woolhandler S and Himmelstein DU. The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly? Ann Intern Med. 2017;167(6):4240431. Accessed at http://annals.org/aim/fullarticle/2635326/relationship-health-insurance-mortality-lack-insurance-deadly
3
10/12/2018 Page 120 Medicaid Expansion: Premium Assistance and Other Options
American College of Physicians A Position Paper 2016
10/12/2018 Page 121 Medicaid Expansion: Premium Assistance and Other Options
A Policy Position Paper of the American College of Physicians
This position paper, written by Ryan A. Crowley, was developed for the Health and Public Policy Committee of the American College of Physicians: Darilyn V. Moyer, MD, FACP (Chair); Douglas M DeLong, MD, FACP (Vice Chair); Sue S. Bornstein, MD, FACP; James F. Bush, MD, FACP; Gregory A. Hood, MD, FACP; Carrie A. Horwitch, MD, FACP; Gregory C. Kane, MD, FACP; Robert H. Lohr, MD, FACP; Kenneth E. Olive, MD, FACP; Shakaib U. Rehman, MD, FACP; Micah Beachy, DO, FACP; Mitch Biermann; Fatima Syed, MD. Approved by the ACP Board of Regents on 16 February 2016.
i
10/12/2018 Page 122 How to cite this paper:
American College of Physicians. Medicaid Expansion: Premium Assistance and Other Options Philadelphia: American College of Physicians; 2016: Position Paper. (Available from American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.)
Copyright © 2016 American College of Physicians
All rights reserved. Individuals may photocopy all or parts of Position Papers for educational, not-for-profit uses. These papers may not be reproduced for commercial, for-profit use in any form, by any means (electronic, mechanical, xerographic, or other) or held in any information storage or retrieval system without the written permission of the publisher.
For questions about the content of this Policy Paper, please contact ACP, Division of Governmental Affairs and Public Policy, Suite 700, 25 Massachusetts Avenue NW, Washington, DC 20001-7401; telephone 202-261-4500. To order copies of this Policy Paper, contact ACP Customer Service at 800-523-1546, extension 2600, or 215-351-2600.
ii
10/12/2018 Page 123 Medicaid Expansion: Premium Assistance and Other Options
Executive Summary The Affordable Care Act (ACA) expanded Medicaid eligibility to all individuals with incomes up to 138% of the federal poverty level (FPL) or about $16,242 for a single adult or $33,465 for a family of four (in 2015). The expansion would pre- dominantly benefit childless adults, a population historically barred from Medicaid regardless of income level, and low-income parents. Opponents of the law argued that the federal law was unduly coercive and challenged the expansion. In 2012, the United States Supreme Court ruled that it is unconstitu- tional for the federal government to coerce states into expanding Medicaid by withholding funding for their existing Medicaid programs if they did not. As a result, Medicaid expansion is now totally optional for the states. As of January 19, 2016, 31 states and the District of Columbia have decided to move forward with the expansion. The remaining states are still considering the matter or have decided against expansion at this time. Following Arkansas’ lead, several states have sought to expand Medicaid coverage in a manner that is more palatable to the conservative ideological lean- ings of their legislators and residents. Using the Medicaid waiver process, which permits Medicaid programs to seek approval from the federal government to forgo some traditional Medicaid rules, states have received approval from the federal government to increase cost-sharing and impose premiums, trim benefits, use Medicaid funds to purchase private insurance, and require or encourage enrollees to participate in wellness or health behavior initiatives. Some past waiver experiments have been widely adopted by state Medicaid programs, including managed care delivery models and benchmark benefit plans.1 This paper will review some of the existing Medicaid expansion waivers and offer recommen- dations designed to influence stakeholders to ensure that Medicaid coverage is expanded in a manner that best suits patients.
Recommendations 1. Medicaid programs must develop and widely disseminate information to enrollees (and potential enrollees) that clearly explains in plain lan- guage health insurance concepts, plan rewards and penalties, provider and hospital network, and other pertinent information. Materials should be made available to meet the needs of the Medicaid population, including those with disabilities and/or limited English proficiency and literacy. States should work with independent enrollment brokers and community-based organizations, and other assistance entities to provide enrollee outreach and education and, when applicable, act as a liaison between the enrollee, insurer, and state program. State programs should work with such stakeholders to provide toll-free help lines, face- to-face counseling, electronic communication and other ways to access Medicaid information, education materials, and enrollment assistance. 2. At a minimum, Medicaid expansion waivers should provide coverage of the essential health benefit package, nonemergency transportation, Early and Periodic Screening and Diagnostic and Treatment benefits, mental health parity, and other benefits required of Alternative Benefit Plans. 3. Medicaid premiums and cost-sharing should be structured in a way that does not discourage enrollment or cause enrollees to disenroll or delay or forgo care due to cost, especially those with chronic disease. If cost- sharing is applied it should be done in a manner that encourages enrollees to seek high-value services and health care physicians and other health care professionals. Medicaid enrollees should not be
1 10/12/2018 Page 124 Medicaid Expansion: Premium Assistance and Other Options
restricted from reenrolling in coverage (i.e., locked-out). Medicaid out- of-pocket costs should remain nominal and be subject to a cap (such as no higher than 5% of family income) for those with incomes above the poverty line. 4. Work-related or job search activities should not be a condition of eligi- bility for Medicaid. Assistance in obtaining employment, such as through voluntary enrollment in skills- and interview-training programs, can appropriately be made available provided that is not a requirement for Medicaid eligibility. 5. Medicaid wellness programs should be structured in a manner that mon- itors health status and encourages healthy behavior through positive incentive-based programs. Punitive approaches that penalize enrollees for not achieving better health status, or for not changing unhealthy behaviors, should be avoided. Applicable programs should adhere to the recommendations established in the ACP policy paper “Ethical Considerations for the Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid and Beyond.”
Background
Premium Assistance and Other Waiver Approaches
Section 1115 of the Social Security Act permits the federal government to approve state Medicaid waivers that provide states additional flexibility as long as they fur- ther program objectives. States have used 1115 waiver authority to expand eligi- bility, to provide new benefits, or to test delivery system reforms. The waivers must be budget neutral. Generally, they are approved for a 5-year period, and then states can apply for a 3-year extension. Some initial Medicaid expansion waivers expire after 3 years. As of January 20, 2016, seven states—Arkansas, Iowa, Michigan, New Hampshire, Indiana, Pennsylvania, and Montana—have had Medicaid expansion waivers approved by the federal government. Since the waivers share a number of characteristics, this section will summarize a selection of waivers and their requirements. To achieve expansion in conservative-leaning states, some governors and legislatures have considered approaches that permit states to use Medicaid funds to purchase private insurance through state health insurance marketplaces, a con- cept known as premium assistance. The Obama Administration has indicated that it would allow some states to implement premium assistance for the Medicaid expansion population, provided that cost-sharing and benefits are comparable to what enrollees would have received if covered by Medicaid. Premium assistance programs must also be cost-effective, meaning that program cost cannot exceed that of providing coverage through Medicaid.2 If a health plan’s benefit package is not as comprehensive as Medicaid’s, the health plan is obligated to integrate wraparound or supplemental benefits to provide the necessary services, although Iowa, Pennsylvania, and Indiana were allowed to temporarily waive nonemergency transportation. States are obligated to fully expand eligibility, so plans that would increase eligibility up to an income level below 138% FPL would not be approved. Premium assistance programs existed before passage of the ACA, usually to help low-income individuals afford individual-market health insurance.3 Given the volatility and high cost of the individual health insurance market before implanta- tion of the ACA’s insurance reforms, Medicaid premium assistance programs were only used to cover small numbers of people.4
2 10/12/2018 Page 125 Medicaid Expansion: Premium Assistance and Other Options
Premium assistance has generated controversy, as patient advocates have questioned whether the private market can provide adequate coverage to meet the needs of a vulnerable population. Individuals with incomes above the poverty level would have lower out-of-pocket spending through Medicaid than if they’d enrolled in a Marketplace-based health plan.5 However, premium assistance may provide benefits that the traditional Medicaid program cannot. Premium assis- tance may reduce “churning,” or a disruption in coverage as enrollee’s income and eligibility status changes, if implemented in a way that ensures continuity as enrollees transition from Medicaid to private market coverage. Physicians and other health providers may be more likely to participate in private insurance than Medicaid, potentially broadening enrollee access to providers. In some states, however, cost-sharing protections for premium assistance programs are only available if the enrollee receives care from a provider that participates in both Medicaid and the enrollee’s private insurance plan network.6 Arkansas was the first state to receive approval for its Medicaid expansion premium assistance program. Since then, several other states have taken interest in the concept. The U.S. Department of Health and Human Services has approved an amended version of Iowa’s premium assistance waiver. New Hampshire will enroll eligible individuals into Medicaid-backed qualified health plans starting in January 2016. Some states have developed Medicaid expansion waiver proposals that would require or encourage jobless beneficiaries to search for employment, par- ticipate in wellness programs, terminate coverage for nonemergency medical transportation, or pay premiums and cost-sharing. This paper will outline char- acteristics of Medicaid expansion waivers and consider their potential effect on patients.
Current Medicaid Expansion Waivers
Arkansas7
The Obama Administration approved Arkansas’ Medicaid premium assistance waiver application in 2013. The waiver allows the state to purchase qualified health plan coverage through the health insurance marketplace for eligible individuals. The pro- gram will run from 2014 to 2016 and cover eligible parents and childless adults. The waiver was amended with federal approval in 2015. In the revised version, nondis- abled individuals with incomes between 50%–138% FPL will be enrolled in plans with “Independence Account” (IA) health savings accounts and contribute monthly pay- ments. These funds will be used to pay cost-sharing.8 Those with incomes above the poverty line will be required to contribute $10–$25 per month; enrollees with incomes from 50%-100% FPL will contribute $5.9 An enrollee cannot lose coverage for failing to pay a premium, but point-of-service cost-sharing will be charged to enrollees with incomes above 100% FPL who do not contribute to their account. Medically frail indi- viduals will be enrolled in traditional Medicaid. Nonemergency transportation and early and periodic screening and diagnostic treatment benefits are provided by Medicaid (wrap-around/supplemental benefits).10 The state waiver also requires prior authorization for nonemergency medical transportation for newly eligible adults. According to the state waiver application, “the introduction of IAs will provide participants with direct information about the cost of health care services and out- of-pocket costs; it also has the goal of promoting independence and self-sufficiency by providing participants with the possibility of having additional credits to be dis- tributed as cash, which can be used to pay future private market premiums.”11
3 10/12/2018 Page 126 Medicaid Expansion: Premium Assistance and Other Options
Iowa
Iowa’s Medicaid expansion waivers are similar to those of Arkansas, although newly eligible adults with incomes from 50%–100% FPL will be covered through Medicaid managed care. Adults with incomes between 101%–138% FPL may enroll in silver-level qualified health plans sold through the state’s health insur- ance marketplace or Medicaid managed care. Iowa will require Medicaid bene- ficiaries to pay premiums starting in 2015: $5 a month for managed care enrollees with incomes from 50%–100% FPL and $10 a month for enrollees with incomes between 101%–138% FPL. Beneficiaries with incomes above the poverty level have a 90-day grace period to pay premiums before their coverage is terminated. Those below the poverty level cannot lose coverage for nonpayment of premi- ums. Premiums can be waived if enrollees participate in wellness activities, includ- ing receiving a health risk assessment and wellness examination.7 Enrollees are obligated to pay a co-pay for nonemergency use of the emergency department (ED). The benefit package for those enrolled in premium assistance will be equiv- alent to the state employee plan benefits package. The state is exempt from nonemergency transportation coverage requirements through July 2015.
Pennsylvania
Pennsylvania’s Medicaid expansion waiver was approved under Governor Tom Corbett in August 2014. Following his election in November 2014, Governor Tom Wolf stated that he will replace the Medicaid waiver with traditional Medicaid expansion. In May 2015, the Philadelphia Inquirer reported that over 120,000 Medicaid enrollees had been transferred from the Healthy Pennsylvania private coverage option to a traditional Medicaid expansion plan called HealthChoices.12 In July, Governor Wolf announced that the final 79,272 enrollees had been trans- ferred to HealthChoices from the Healthy Pennsylvania waiver program.13 Before the transition to HealthChoices, the Healthy Pennsylvania program provided services to the expansion population through Medicaid managed care arrangements. Starting in January 2016, the state would charge premiums of up to 2% of household income for enrollees with incomes over the FPL. Enrollees required to pay premiums would not have to pay copayments except for an $8 charge for nonemergency use of the ED.14 People with income below the poverty level would pay co-payments. Those who failed to pay the plan premium would have a 90-day grace period before coverage would be terminated. Some groups, such as pregnant women and the medically frail, would be exempt from premium requirements. Premium amounts could be reduced if the enrollee participated in healthy behavior activities, such as having an annual wellness visit. The expan- sion population would receive the “full complement of health services required under the law,” although like the Iowa waiver, the state was exempt from non- emergency medical transportation requirements until 2016. Pennsylvania’s proposed waiver application included a provision that would reduce premiums and cost-sharing for adult enrollees who participate in a vol- untary work-search pilot program. The federal government rejected this proposal but the state indicated that it would provide career coaching for enrollees who voluntarily participate in the state’s Encouraging Employment program.
4 10/12/2018 Page 127 Medicaid Expansion: Premium Assistance and Other Options
Indiana
The Healthy Indiana Plan 2.0 (HIP) was approved by HHS in 2015 and is scheduled to run until January 2018. A Kaiser Family Foundation summary of the waiver notes “while all [Medicaid] waivers involve some amount of administrative complexity, Indiana’s demonstration is more complex than others approved to date.”15 Under HIP 2.0, enrollees, including the adult expansion population, will be enrolled into a HIP Plus plan, which is connected to a Personal Wellness and Responsibility (POWER) health savings-style account. The POWER account seeks to “promote more efficient use of health care, encouraging preventive care and discouraging unnecessary care.”16 HIP Plus enrollees are required to contribute to a Personal Wellness and Responsibility (POWER) health savings account and in exchange will have access to a wider array of benefits, including dental and vision, in addi- tion to the ACA-mandated essential health benefit package.17 The state will also make financial contributions to the enrollee’s POWER account to cover health care expenses. Indiana is not obligated to offer nonemergency medical trans- portation to the newly eligible adult population through November 2016.18 Indiana is authorized to collect monthly premiums in the form of POWER account contributions. Contributions are not to exceed 2% of household income for those with incomes up to 133% FPL. Contributions for enrollees with incomes up to 5% FPL are capped at $1 a month. Above-the-poverty-line enrollees are required to make contributions to POWER accounts as a condition of coverage. HIP Plus enrollees will not be subject to cost-sharing except for nonemergency use of the ED ($8 for first use, $25 for subsequent visits). Above-poverty-level enrollees will lose coverage and be subject to a six- month “lock-out” if they begin and then subsequently stop contributing to their POWER account. They will be barred from reenrolling in coverage during the lock-out period. Those with incomes below the poverty line who do not con- tribute to a POWER account will receive HIP Basic benefits and be required to pay Medicaid-level cost-sharing (i.e., “nominal” amount). HIP Basic enrollees will also be denied vision, dental, and some prescription drug benefits. For above-the-poverty-line enrollees, coverage starts on the first day of the month in which a POWER account contribution is made, rather than the date of the Medicaid application.
Recommendations 1. Medicaid programs must develop and widely disseminate information to enrollees (and potential enrollees) that clearly explains in plain lan- guage health insurance concepts, plan rewards and penalties, provider and hospital network, and other pertinent information. Materials should be made available to meet the needs of the Medicaid population, including those with disabilities and/or limited English proficiency and literacy. States should work with independent enrollment brokers and community-based organizations, and other assistance entities to provide enrollee outreach and education and, when applicable, act as a liaison between the enrollee, insurer, and state program. State programs should work with such stakeholders to provide toll-free help lines, face- to-face counseling, electronic communication and other ways to access Medicaid information, education materials, and enrollment assistance.
5 10/12/2018 Page 128 Medicaid Expansion: Premium Assistance and Other Options
Much of the newly eligible Medicaid population may not understand health insurance concepts like cost-sharing, networks, and formularies.19 Individuals with lower health insurance literacy and numeracy skills may be less able to adequately compare high-deductible health plans versus traditional plans20 or comprehend hospital quality information.21 Evidence shows that Medicaid beneficiaries may have difficulty understanding and navigating health-related incentive programs, like wellness/healthy behavior incentive efforts, resulting in low participation.22 A survey of uninsured Medicaid-eligible adults found that only 18.7% were very or somewhat confident in their understanding of all insurance terms listed in the sur- vey (i.e., premiums, deductibles, co-payments, coinsurance, maximum annual out- of-pocket spending, provider networks, annual limits on services, covered services non-covered and excluded services).19 To address this problem, public informa- tion and education campaigns initiated by State Medicaid programs and health insurance marketplaces should clearly explain insurance concepts in a manner that reflects the language and cultural needs of the target population.23 Wellness program educational materials should be written in plain language and dissemi- nated through multiple modes of communication to ensure that individuals are educated on how programs work and the incentives available for meeting goals or penalties for failing to meet goals.22, 24 As Medicaid programs become more complex, materials need to be present- ed in a manner and reading level that is accessible to the Medicaid population. Ninety percent of states have reading level requirements for their Medicaid mate- rials; most mandate that materials be written at a 6th grade reading level.25 Multilingual Medicaid informational materials and translation services should be made available since more than half of people with limited English proficiency have incomes that would make them eligible for Medicaid.26, 27 The Medicaid and CHIP Payment Access Commission (MACPAC) has recommended that when Medicaid programs transition from fee-for-service to private managed care, it is important to communicate to enrollees “how to obtain services in the most appro- priate manner; the procedures for making plan selection and the implications of those choices; the concept of auto-assignment for those who do not select a plan; and the importance of acting in a timely manner so that enrollment cards and new member materials can be issued.”28 Research shows that patients trust physi- cians and other health providers when seeking health insurance information.19, 29 Physicians and office staff should be prepared to provide or refer patients to health insurance enrollment and education information. States should simplify enrollment and eligibility checks and work with health insurance marketplace-based outreach and enrollment entities to facilitate Medicaid coverage. The ACA requires that the enrollment infrastructure for Medicaid and private health insurance marketplace-based plans be streamlined and coordinated. Programs must coordinate efforts and information technology infrastructure to ensure that applicants have “no wrong door” when seeking cov- erage. Fast-track enrollment procedures or Express Lane enrollment can also make it easier for people to obtain coverage. Enrollment applications and plan information can be distributed in a targeted manner to those who participate in other social service programs, such as Supplemental Nutrition Assistance Program (SNAP, previously known as the Food Stamp Program).30 Arkansas identified and mailed Medicaid enrollment applications to SNAP-participating individuals and families.31 South Carolina has used fast-track procedures to renew Medicaid cov- erage for individuals who are also enrolled in SNAP and the Temporary Assistance for Needy Families program, reducing administrative costs and staff time.32
2. At a minimum, Medicaid expansion waivers should provide coverage of the Essential Health Benefit package, nonemergency transportation, Early and Periodic Screening and Diagnostic and Treatment benefits, mental health parity, and other benefits required of Alternative Benefit Plans.
6 10/12/2018 Page 129 Medicaid Expansion: Premium Assistance and Other Options
Most of the Medicaid expansion population will receive a Medicaid alterna- tive benefit plan (ABP) which includes the 10 Essential Health Benefit categories required of private market health exchange plans, mental health parity require- ments, preventive services, family planning services, and nonemergency trans- portation services, among others. Many states have based their ABP on the ben- efit package available to traditional adult Medicaid enrollees. ACP policy recommends that:
States’ efforts to reform their Medicaid programs should not result in reduced access to care for patients. Consumer-driven health care reforms established in Medicaid should be implemented with caution and consider the vulnerable nature of the patients typically served by Medicaid. A core set of compre- hensive, evidence-based benefits must be provided to enrollees.33
Nonemergency transportation services are a staple of state Medicaid pro- grams and help low-income individuals without adequate transportation make their health care appointments. Limited transportation options were cited by Florida and Idaho Medicaid enrollees as barriers to participating in wellness/healthy behaviors programs.24 In its Arkansas Health Reform Legislative Task Force–requested assessment of the Arkansas Medicaid program, The Stephen Group consulting firm described the nonemergency transportation ben- efit as a “very cost effective benefit” and recommended that the state keep the benefit in place.34 Patient advocate groups in Pennsylvania criticized the state’s attempt to revise benefit and cost-sharing requirements for currently eligible Medicaid enrollees, insisting that they would hurt the poor and vulnerable.35 ACP has long supported policies that support an essential benefits package. The Obama Administration has maintained that premium assistance programs ensure that benefits are equal to what an enrollee would receive through a traditional expansion. Slashing transportation benefits, or making certain benefits available only to those who participate in wellness programs or similar initiatives, under- mines the concept of an essential benefit package.
3. Medicaid premiums and cost-sharing should be structured in a way that does not discourage enrollment or cause enrollees to disenroll or delay or forgo care due to cost, especially those with chronic disease. If cost- sharing is applied it should be done in a manner that encourages enrollees to seek high-value services and health care physicians and other health care professionals. Medicaid enrollees should not be restricted from reenrolling in coverage (i.e., locked-out). Medicaid out- of-pocket costs should remain nominal and, for those with incomes above the poverty line, be subject to a cap (such as no higher than 5% of family income).
Premiums and Cost-Sharing in Medicaid
Federal law restricts Medicaid from establishing premiums for enrollees with incomes under 150% FPL. However, the federal government has granted Medicaid expansion waivers that allow the collection of premiums or mandatory contributions to health savings accounts that may have the same effect as premi- ums. Premiums pose a financial barrier to low-income individuals and may dis- courage Medicaid enrollment or cause disenrollment.36 Evidence shows that cost-sharing can be effective in reducing use of unnecessary health care services; however, it also has been shown to decrease use of effective care and have an adverse impact on the poorest and sickest patients. The large-scale, multi-year (1971–1982) RAND Health Insurance Experiment found the following:
7 10/12/2018 Page 130 Medicaid Expansion: Premium Assistance and Other Options
• “Participants who paid for a share of their health care used fewer health services than a comparison group given free care. • Cost-sharing reduced the use of both highly effective and less-effective services in roughly equal proportions. • Cost-sharing did not significantly affect the quality of care received by participants. Cost-sharing in general had no adverse effect on participant health, but there were exceptions: free care led to improvements in hypertension, dental health, vision, and selected serious symptoms. These improvements were concentrated among the sickest and poorest patients.”37 • A 2006 report on the RAND experiment “the study suggested that cost- sharing should be minimal or nonexistent for the poor, especially those with chronic disease.”
Despite Medicaid’s generous coverage, a study done before the 2014 Medicaid expansion found that 26% of Medicaid enrollees were underinsured, with out-of-pocket expenses higher than 5% of annual household income.38 Many states impose some limited cost-sharing on Medicaid beneficiaries in an effort to fill budget gaps and curb unnecessary spending. Below-poverty-level enrollees can only be subject to “nominal” cost-sharing. The Obama Administration has given states some flexibility in the amount of cost-sharing for the expansion pop- ulation while rejecting proposals to terminate coverage if a below-poverty-level enrollee does not pay the premium or out-of-pocket fee. Evidence shows that high cost-sharing can drive enrollees out of Medicaid.39, 40 In response to an eco- nomic downturn, Oregon cut benefits, increased premiums, and established cost-sharing for some Oregon Health Plan (OHP) Standard enrollees (including nondisabled adults and couples with incomes below the poverty level), and enrollees left the program in droves. When asked why they had disenrolled, nearly half of survey respondents cited premium increases and inflexible premi- um payment deadlines as reasons for leaving the program within the first 6 months after the plan's changes were implemented.40 Those that remained in the program were more likely to report cost as a barrier to getting needed care than those in the more-generous OHP Plus plan. States that increase Medicaid cost-sharing have lower take-up rates than those with limited cost-sharing, indi- cating that cost-sharing influences whether an eligible individual enrolls.41 States may eventually save money, not because of premium savings but because Medicaid premiums cause people to disenroll from the program.42 Cost-sharing may dissuade lower-income individuals from seeking necessary care: a Commonwealth Fund survey found that insured adults with incomes under 200% FPL were more likely than their higher-income counterparts to report delaying or avoiding care because of their copayments or coinsurance.43 Some have cau- tioned that policies intended to shift the financial burden of care to the enrollee may not control program spending in part because existing Medicaid managed care arrangements already discourage unnecessary care.44
Nonemergency Use of the Emergency Department
ACP has expressed concern about imposing cost-sharing for nonemergency use of EDs. In a letter to CMS, the College stated:
8 10/12/2018 Page 131 Medicaid Expansion: Premium Assistance and Other Options
While the College strongly supports the delivery of health care services by the most appropriate physician or other health care provider in the most appropriate setting, it should be acknowledged that patients in underserved areas may have no other option but to visit an emergency department to receive care. A patient may also believe their condition to be more severe than the reality, leading them to visit the emergency department as a pre- cautionary measure even when the condition could be handled by a primary care physician.45
Some Medicaid programs have established cost-sharing for nonemergency use of EDs. Federal regulations permit states to implement an $8 copay for non- emergency use of the ED only after screening and referring beneficiaries to an appropriate provider has been attempted.46 MACPAC found that only 10% of Medicaid-covered ED visits made by nonelderly patients were unnecessary.47 Nonemergency use of ED may indicate that the patient cannot access the most appropriate clinician, such as a primary care physician or subspecialist.48 Patients may also be unable to determine if their symptoms, such as chest pain, require urgent attention, and such conclusions may only be possible with a physician evaluation.47 Further, one study found that “granting states permission to collect copayments for non-urgent visits under the [Deficit Reduction Act of 2005] did not significantly change ED or outpatient medical provider use among Medicaid beneficiaries”, indicating that requiring cost-sharing may not effectively discour- age unnecessary use of the ED.49 States should consider factors like primary care access and patient health literacy when deciding whether to require cost-sharing for nonemergency use of EDs and consider policy alternatives that direct patients to the proper health care setting. Better collaboration, patient education, and case management can also reduce nonemergency use of the emergency department. Washington State’s “ER is for Emergencies” program, a private–public partnership involving the state’s governmental health care authority and emergency physician, hospital, and med- ical associations, seeks to reduce nonemergency use of the ED and Medicaid costs by promoting information exchange and collaboration. The program’s 7 best practices are to develop and share information through the Emergency Department Information Exchange system, educate patients about appropriate care settings, track frequent ED and emergency medical service users, create care plans for frequent ED users, utilize narcotic guidelines to reduce “narcotic- seeking behavior” by patients, engage in a prescription-monitoring program, and use feedback information to ensure interventions are successful.50 In the first year of the program, 420 primary care providers were notified when their patients entered the ED, the rate of ED visits dropped by nearly 10%, the rate of visits with a low-acuity diagnosis decreased by 14.2%, and about $34 million in emer- gency costs was saved.51
Premium Assistance and Health Savings Accounts
Cost-sharing for private insurance is typically much higher than Medicaid; one study found that out-of-pocket spending would be seven times higher for adults covered under private insurance than Medicaid.52 This underscores the need to ensure that premium assistance waivers provide a level of benefits and cost-shar- ing comparable to what enrollees would receive under a traditional, non-waiver eligibility expansion. A number of states have sought to place Medicaid enrollees into health plans connected to health savings accounts or other medical expense savings accounts, such as Indiana’s POWER accounts. Proponents of such plans argue that they
9 10/12/2018 Page 132 Medicaid Expansion: Premium Assistance and Other Options
teach enrollees to be more cost-conscious about health care purchases, cultivate personal responsibility, and encourage shopping around for the best price or highest quality provider or service. However, a April 2015 Kaiser Family Foundation survey reported that information on medical care costs is hard to find, with 64% responding that finding cost and quality information was difficult.53 Those that do report finding cost and quality information on hospitals, physicians, or health plans, do not use such information when making a decision about health care. Similarly, some Medicaid experiments, such as the mid-2000s Florida con- sumer-driven health insurance pilot, seek to encourage enrollees to comparison shop for plans based on cost-sharing, quality, and additional services. In the case of the Florida experiments, most enrollees made their decisions based on physi- cian location, physician network, and prior enrollment in the plan, rather than cost or generosity of benefits.21 This may indicate that enrollees are overwhelmed by the number of plan choices (which may lead them to stay in their existing plan), do not understand plan explanations, or that physician and other health care pro- fessional preferences are a substantial motivator of plan choice.
Value-Driven Cost-Sharing
Cost-sharing cannot be used as a blunt instrument, especially because the Medicaid-eligible population is particularly price sensitive. Increased cost-sharing for medications is associated with higher use of inpatient services and the ED among the chronically ill.54 Cost-sharing structures that reduce prescription drug utilization have been found to increase Medicare costs and hospital use.55 ACP policy supports cost-sharing requirements for the adult Medicaid expansion pop- ulation if they are structured in a way that encourages use of high-value services and do not deter patients from accessing necessary care. For instance, reducing co-payments for cholesterol-lowering medication for sicker patients has been shown to reduce both hospitalizations and health care spending.56 Such efforts should be closely monitored to determine potential underutilization of necessary care and whether access to high-quality care is compromised.
4. Work-related or job search activities should not be a condition of eligi- bility for Medicaid. Assistance in obtaining employment, such as through voluntary enrollment in skills- and interview-training programs, can appropriately be made available provided that is not a requirement for Medicaid eligibility.
Most Medicaid-eligible individuals are already working or have a family mem- ber working. Those that are uninsured and unemployed report they are unable to find employment (20%), taking care of home or a family member (29%), ill or disabled (17%) are going to school (18%) as their main reason for unemployment.57 The work search requirement provisions originally proposed by Pennsylvania drew substantial criticism from advocates for the poor as well as health policy experts, who argued that work programs are outside of the health- focused intent of the Medicaid statute.35 Early versions of the state’s waiver required participation in a work search program but subsequent versions made participation voluntary.58 The work search pilot was part of the waiver’s “personal responsibility” section, which also included premiums for higher-income enrollees and premium and cost-sharing reductions for those who pay copay- ments on time and receive an annual wellness visit, followed by a Health Risk Assessment in year 2.59 The work search provision intended to “enable low- income, able bodied Pennsylvanians [to] move out of poverty while also gaining access to health coverage.”59 The state argued that the program is necessary
10 10/12/2018 Page 133 Medicaid Expansion: Premium Assistance and Other Options because research shows that “being employed results in improved physical and mental health.” Pennsylvania’s final waiver omitted a work search requirement. In its place, Medicaid enrollees can voluntarily participate in state-sponsored job- training and work-related activities. Proponents argue that work requirements were central to the 1990s welfare reform effort and would reduce dependency on the public insurance program.60 However, Medicaid was established to provide medical assistance for low-income individuals. It is not designed to provide job training to enrollees.61 There may also be jurisdictional limitations to imposing work or job-search requirements, since the U.S. Department of Health and Human Services does not have the author- ity to restrict coverage based on such requirements.1 Waiver proposals that would require such activities should not be approved. Similar to wellness programs, there is also the concern that voluntary work-related programs that reduce pre- miums and cost-sharing for participants could be coercive and effectively non- voluntary if they penalize those who do not participate by imposing higher costs. Such structures should be discouraged in expansion waiver programs.
5. Medicaid wellness programs should be structured in a manner that mon- itors health status and encourages healthy behavior through positive incentive-based programs. Punitive approaches that penalize enrollees for not achieving better health status or for not changing unhealthy behaviors, should be avoided. Applicable programs should adhere to the recommendations established in the ACP policy paper “Ethical Considerations for the Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid and Beyond.”
Some premium assistance programs would also encourage participation in health promotion and wellness activities. Pennsylvania proposed to reduce cost- sharing and premiums for enrollees that receive an annual wellness visit and health risk assessment. Wellness programs are popular among employers and may help reduce cost and improve health. A literature review of workplace well- ness programs found that medical costs dropped by $3.27 for every dollar spent on wellness programs and employee absenteeism costs were reduced by $2.73 for every dollar spent.62 The literature supports that preventive care incentives may be most effective to encourage a single activity, like getting vaccinated, than for regular activity like participation in smoking cessation program.22 However, only a handful of states have initiated wellness programs to influence Medicaid enrollee health behavior. The ACA-authorized Medicaid Incentives for Prevention of Chronic Diseases grant program is designed to help states create, implement, and evaluate health prevention programs that aim to curb tobacco use, control weight, lower blood pressure, and reach other goals. Generally, the College believes that as long as patient privacy protections are in place, nondiscrimination rules are strongly enforced, and physician admin- istrative cost and burden are minimized, evidence-based wellness programs can have a positive impact on health by encouraging prevention and discouraging unhealthy behaviors. College policy recommends that employers and health plans should fund programs proven to be effective in reducing obesity, stopping smoking, deterring alcohol abuse, and promoting wellness and providing cov- erage or subsidies for individuals to participate in such programs.63
11 10/12/2018 Page 134 Medicaid Expansion: Premium Assistance and Other Options
However, important safeguards must be established to prevent wellness pro- grams from discriminating against or disproportionately penalizing patients or impeding access to care. ACP policy recommends that:
Incentives to promote behavior change be designed to allocate health care resources fairly without discriminating against a class or category of people. The incentive structure must not penalize individuals by withholding benefits for behaviors or actions that may be beyond their control.
The College supports “use of positive incentives for patients such as pro- grams and services that effectively and justly promote physical and mental health and well-being.”64 The College’s position paper notes that patient advocacy organizations are skeptical of using financial incentives to change behavior: “These advocacy orga- nizations do not believe that the use of financial incentives linked to health insur- ance premiums, deductibles or other patient costs are an appropriate way to motivate behavior change.” Preliminary evidence from the Iowa Health and Wellness Plan, where 2015 Medicaid premiums are waived if enrollees receive a physical examination and participate in a health risk assessment in the previous year, found that only 15% had completed both required activities as of January 2015.65 One explanation for the low response rate is that the education materials were not distributed until May 2014, about 5 months after the beginning of enroll- ment.66 A study evaluating Medicaid wellness incentive demonstration programs recommended offering substantial incentives to encourage participation, com- prehensible and accessible instructions on how to participate and the benefits of doing so, and ongoing evaluation to determine program efficacy. Wellness incentive programs adopted by state Medicaid programs should be evidence- based and proven to effectively encourage health behavior before widespread implementation. Wellness programs should not impose any excessive adminis- trative burden on physicians or require them to infringe on their patient’s right to privacy. ACP discourages programs that deny benefits or impose higher pre- miums or cost-sharing to enrollees that opt out of wellness programs.
Conclusion
Waivers are intended to grant states flexibility to expand Medicaid in a way that recognizes local considerations and conditions. States that have pursued post-expansion waivers have generally sought to increase the reach and influence of private insurance market concepts through premium assistance, premiums, cost-sharing, and health savings accounts. Some states have attempted to expand Medicaid’s breadth to influence enrollee work status and job-search habits, an area traditionally beyond the program’s charge. Since waivers are temporary, it is important that state Medicaid programs, patient advocacy organizations, physi- cian and other health care professional groups, and others closely monitor the effects of waiver experiments to better understand the effect of premiums on poor and/or chronically ill patients; provider accessibility and participation; whether Marketplace-based plans are preferable to existing Medicaid managed care arrangements; and the effect of these waivers on administrative complexities, enrollee satisfaction, and overall cost.
12 10/12/2018 Page 135 Medicaid Expansion: Premium Assistance and Other Options
References 1 Rosenbaum S and Hurt C. How States Are Expanding Medicaid to Low-Income Adults Through Section 1115 Waiver Demonstrations. Commonwealth Fund. December 2014, Accessed at http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2014/dec/1794_ rosenbaum_states_expanding_medicaid_section_1115_rb_v3.pdf?la=en on May 6, 2015.
2 U.S. Department of Health and Human Services. Medicaid and the Affordable Care Act: Premium Assistance Frequently Asked Questions. March 2013. Accessed at http://medicaid.gov/Federal- Policy-Guidance/Downloads/FAQ-03-29-13-Premium-Assistance.pdf on May 3, 2014.
3 Alker J. Is There a New Premium Assistance Option in the Air? Georgetown University Health Policy Institute. February 8, 2013. Accessed at http://ccf.georgetown.edu/all/is-there-a-new- premium-assistance-option-in-the-air/ on October 9, 2015
4 Mahan D. Expanding Medicaid Using Premium Assistance, or the “Private Option,” to Buy Health Insurance. Families USA. June 2013. Accessed at http://familiesusa.org/sites/default/files/ product_documents/Premium-Assistance.pdf
5 Hill S. Medicaid Expansion in Opt-Out States Would Produce Consumer Savings and Less Financial Burden than Exchange Coverage. Health Aff. 2015;34(2);340-349. Accessed at http://content.healthaffairs.org/content/34/2/340.full on May 6, 2015.
6 Alker J, Miskell S, Musumeci M, Rudowitz R. Medicaid Premium Assistance Programs: What Information is Available About Benefit and Cost-Sharing Wrap-around Coverage? Kaiser Commission on Medicaid and the Uninsured. December 2015. Accessed at http://files.kff.org/ attachment/issue-brief-medicaid-premium-assistance-programs-what-information-is-available- about-benefit-and-cost-sharing-wrap-around-coverage on January 19, 2016
7 Kaiser Family Foundation. Medicaid Expansion Through Premium Assistance: Arkansas, Iowa, and Pennsylvania’s Proposals Compared. April 4, 2014. Accessed at http://kff.org/health-reform/fact- sheet/medicaid-expansion-through-premium-assistance-arkansas-and-iowas-section-1115-demon- stration-waiver-applications-compared/ on May 4, 2014.
8 Kaiser Family Foundation. Medicaid Expansion in Arkansas. February 12, 2015. Accessed at http://kff.org/medicaid/fact-sheet/medicaid-expansion-in-arkansas/ on April 22, 2015.
9 Arkansas Medicaid. 2015 Changes to Arkansas’s Private Option: Independence Accounts, Cost Sharing, and Nonemergency Medical Transportation. August 7, 2014. https://www.medicaid.state.ar.us/Download/general/comment/HCIWPresentation2015.pdf
10 Tavenner M. Letter regarding Arkansas Health Care Independence Program (Private Option). Centers for Medicare and Medicaid Services. September 27, 2013. Accessed at http://www. medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/ ar-private-option-ca.pdf on May 4, 2014.
11 Stehle D. Letter to The Honorable Sylvia Mathews Burwell. Arkansas Department of Human Services Division of Medical Services. September 15, 2014. Accessed at http://www.medicaid.gov/Medicaid- CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/ar-private-option-pa.pdf on April 23, 2015.
12 Calandra R. Pa. unravels Corbett’s health-plan mess. Philadelphia Inquirer. May 3, 2015. Accessed at http://www.philly.com/philly/health/healthcare-exchange/20150503_Pa__unravels_Corbett_s_ health-plan_mess.html on May 4, 2015.
13 Office of Governor Tom Wolf. PA Transitions Final 79,272 Individuals into Expanded Medicaid Program. July 27, 2015. Accessed at https://www.governor.pa.gov/pennsylvania-transitions-final- 79272-individuals-into-expanded-medicaid-program/ on August 24, 2015.
13 10/12/2018 Page 136 Medicaid Expansion: Premium Assistance and Other Options
14 U.S. Department of Health and Human Services. Letter to Secretary Beverly Mackereth, Pennsylvania Department of Public Welfare. August 28, 2014. Accessed at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/ downloads/pa/pa-healthy-ca.pdf on April 23, 2015.
15 Kaiser Commission on Medicaid and the Uninsured. Mediciad Expansion in Indiana. February 2015. Accessed at http://files.kff.org/attachment/fact-sheet-medicaid-expansion-in-indiana on April 23, 2015.
16 Healthy Indiana Plan 2.0 section 1115 Medicaid Demonstration Fact Sheet. Accessed at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/ downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-fs.pdf on April 23, 2015.
17 Rudowitz R, Artiga S, and Musumeci M. The ACA and Medicaid Expansion Waivers. Kaiser Family Foundation. February 17, 2015. Accessed at http://kff.org/report-section/the-aca-and-medicaid- expansion-waivers-issue-brief/ on April 23, 2015.
18 Fishman E. Letter to Joseph Moser, Medicaid Director, Indiana Family and Social Services Administration. December 22, 2015. Accessed at https://www.medicaid.gov/Medicaid-CHIP- Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy- indiana-plan-support-20-response-ltr-12222015.pdf on January 20, 2016.
19 Kenney GM, Karpman M, Long SK. Uninsured Adults Eligible for Medicaid and Health Insurance Literacy. December 2013. Accessed at http://hrms.urban.org/briefs/medicaid_experience.pdf on May 5, 2015.
20 Greene J, Peters E, Mertz CK, Hibbard JH. Comprehension and Choice of a Consumer-Directed Health Plan: An Experimental Study. Am J Manag Care. 2008;14(6): 369-376. Accessed at http://www.ajmc.com/journals/issue/2008/2008-06-vol14-n6/jun08-3300p369-376/P-1 on May 5, 2015.
21 Green J and Peters E. Medicaid Consumers and Informed Decisionmaking. Health Care Financ Rev. 2009;30(3): 25-40. Accessed at http://146.123.140.205/Research-Statistics-Data-and- Systems/Research/HealthCareFinancingReview/Downloads/09SpringPg25.pdf on May 5, 2015.
22 Blumenthal KJ, Saulsgiver KA, Norton L, Troxel AB, Anarella JP, Gesten FC, Chernew ME, Volpp KG. Medicaid Incentive Programs to Encourage Healthy Behavior Show Mixed Results to Date and Should Be Studied and Improved. Health Aff. 2013;32(3): 497-507. Accessed at http://content.healthaffairs.org/content/32/3/497.full on May 4, 2015.
23 Mahan D. Expanding Medicaid Using Premium Assistance, or the “Private Option,” to Buy Health Insurance. Families USA. June 2013. Accessed at http://familiesusa.org/sites/default/files/prod- uct_documents/Premium-Assistance.pdf
24 Barth J and Greene J. Encouraging Healthy Behaviors in Medicaid: Early Lessons from Florida and Idaho. Center for Health Care Strategies, July 2007. Accessed at http://www.chcs.org/media/Encouraging_Healthy_Behaviors_in_Medicaid.pdf on May4, 2015.
25 Health Literacy Innovations. National Survey of Medicaid Guidelines for Health Literacy. Accessed at http://adph.org/ALPHTN/assets/060110survey.pdf on May 5, 2015.
26 Gonzales G. State Estimates of Limited English Proficiency (LEP) by Health Insurance Status. State Health Access Data Assistance Center. Brief 40. May 2014. Accessed at http://www.rwjf.org/con- tent/dam/farm/reports/issue_briefs/2014/rwjf414189 on May 6, 2015
27 Kaiser Commission on Medicaid and the Uninsured. Overview of Health Coverage for Individuals with Limited English Proficiency. August 2012. Accessed at https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8343.pdf on May 6, 2015.
14 10/12/2018 Page 137 Medicaid Expansion: Premium Assistance and Other Options
28 Medicaid and CHIP Payment Advisory Commission. Report to Congress: The Evolution of Managed Care in Medicaid. June 2011. Accessed at https://www.macpac.gov/publication/report- to-congress-the-evolution-of-managed-care-in-medicaid/ on August 13, 2015.
29 U.S. Department of Health and Human Services. America’s Health Literacy: Why We Need Accessible Health Information. 2008. Accessed at http://health.gov/communication/literacy/ issuebrief/#adults on August 14, 2015.
30 Guyer J and Schwartz T. Operationalizing the New Fast Track Enrollment Options: A Roadmap for State Officials. Robert Wood Johnson Foundation. November 2013. Accessed at http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf409359 on August 18, 2015.
31 Hagan L. Enroll America’s State Site Visits: Key Takeaways for Future Outreach and Enrollment. March 7, 2014. Accessed at https://www.enrollamerica.org/blog/2014/03/enroll-americas-state- site-visits-key-takeaways-for-future-outreach-and-enrollment/ August 18, 2015.
32 Goodwin K and Tobler L. Medicaid and Marketplace Outreach and Enrollment Options for States. National Conference of State Legislatures. May 2014. Accessed at http://www.ncsl.org/docu- ments/health/MedicaidandMarketplaceOandEOptionsforStates514.pdf on August 18, 2015.
33 American College of Physicians. Medicaid and Health Care Reform. Philadelphia: American College of Physicians; 2011: Policy Paper. Accessed at https://www.acponline.org/acp_policy/poli- cies/medicaid_healthcare_reform_2011.pdf on August 24, 2015.
34 The Stephen Group. The Stephen Group Volume II: Recommendations to Arkansas Health Reform Task Force Regarding Health Care Reform/Medicaid Consulting Services. October 2015. Accessed at http://www.arkleg.state.ar.us/assembly/2015/Meeting%20Attachments/836/ I14099/TSG%20Volume%20II%20Recommendations.pdf January 20, 2016
35 Worden A and Sapatkin D. Corbett’s Final Medicaid Expansion Plan: Gentler, but Still an Outlier. Philadelphia Inquirer. February 20, 2014. Accessed at http://www.kaiserhealthnews.org/ Stories/2014/February/20/corbett-submits-medicaid-waiver-plan.aspx on May 5, 2015.
36 Snyder L and Rudowitz R. Premiums and Cost-Sharing in Medicaid: A Review of the Evidence. Kaiser Commission on Medicaid and the Uninsured. February 2013. Accessed at https://kaiserfam- ilyfoundation.files.wordpress.com/2013/02/8417-premiums-and-cost-sharing-in-medicaid.pdf
37 Brook RH, Keeler EB, Lohr KN, Newhouse JP, Ware JE, Rogers WH, Davies AR, Sherbourne CD, Goldberg GA, Camp P, Kamberg C, Leibowitz A, Keesey J, Reboussin D. The Health Insurance Experiment: A Classic RAND Study Speaks to the Current Health Care Reform Debate. 2006. Accessed at http://www.rand.org/pubs/research_briefs/RB9174.html on April 27, 2015
38 Magge H, Cabral HJ, Kazis LE, Sommers BD. Prevalence and Predictors of Underinsurance Among Low-Income Adults. J Gen Intern Med. 2013;28(9):1136-1142. Accessed at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3744314/ on October 8, 2015.
39 Wright BJ, Carlson MJ, Edlund T, Devoe J, Gallia C, Smith J. The Impact of Increased Cost Sharing on Medicaid Enrollees. Health Aff. 2005;24(4):1106-1116. Accessed at http://content.healthaf- fairs.org/content/24/4/1106.long on April 27, 2015
40 Wright BJ, Carlson MJ, Allen H, Holmgren AL, Rustvold DL. Raising Premiums and Other Costs for Oregon Health Plan Enrollees Drove Many to Drop Out. Health Aff. December 2010; 29(12): 2311-2316.
41 Sommers BD, Tomasi MR, Swartz K, Epstein AM. Reasons for the Wide Variation in Medicaid Participation Rates Among States Hold Lessons for Coverage Expansion in 2014. Health Aff. 2012;31(5):909-918. Accessed at http://content.healthaffairs.org/content/31/5/909.full on April 27, 2015
15 10/12/2018 Page 138 Medicaid Expansion: Premium Assistance and Other Options
42 Saloner B, Sabik L, Sommers BD. Pinching the Poor? Medicaid Cost Sharing under the ACA. N Engl J Med. 2014;370:1177-1180. Accessed at http://www.nejm.org/doi/full/10.1056/NEJMp1316370 on April 24, 2015.
43 Collins SR, Rasmussen PW, Doty MM, Beutel S. Too High a Price: Out-of-Pocket Health Care Costs in the United States: Findings from the Commonwealth Fund Health Care Affordability Tracking Survey, September-October 2014. Commonwealth Fund. November 2014. Accessed at http://www.commonwealthfund.org/~/media/files/publications/issue- brief/2014/nov/1784_collins_too_high_a_price_out_of_pocket_tb_v2.pdf on April 24, 2015.
44 Holahan J and Weil A. Toward Real Medicaid Reform. Health Aff. 2007;26(2):w254-w270. Accessed at http://content.healthaffairs.org/content/26/2/w254.full.pdf on April 27, 2015
45 American College of Physicians. Letter to Cindy Mann, Centers for Medicare and Medicaid Services. February 21, 2013. Accessed at http://www.acponline.org/advocacy/where_we_stand/assets/medicaid_benefit_plan.pdf on May 11, 2015.
46 Jost T. Implementing Health Reform. Final Rule on Premium Tax Credit, Medicaid, and CHIP Eligibility Determinations. (Part 2). Health Affairs Blog. July 7, 2013. Accessed at http:// healthaffairs.org/blog/2013/07/07/implementing-health-reform-final-rule-on-premium-tax- credit-medicaid-and-chip-eligibility-determinations-part-2/ on May 5, 2014.
47 MACPAC. Revisiting Emergency Department Use in Medicaid. July 2014. Accessed at http://tinyurl.com/nzabuyh on May 11, 2015.
48 Kellerman A and Weinick RM. Emergency Departments, Medicaid costs, and Access to Primary Care—Understanding the Link. N Engl J Med. 2012;366:2141-2143. Accessed at http://www.nejm.org/doi/full/10.1056/NEJMp1203247 on May 5, 2014.
49 Siddique M, Roberts ET, Pollack CE. The Effect of Emergency Department Copayments for Medicaid Beneficiaries Following the Deficit Reduction Act of 2005. JAMA Intern Med. 2015; 175(3):393-398. Accessed at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4441261/ on August 19, 2015.
50 Washington State Hospital Association, Washington State Medical Association, American College of Emergency Physicians Washington Chapter, Washington State Health Care Authority. ER is for Emergencies: Seven Best Practices. January 2015. Accessed at http://www.wsha.org/wp- content/uploads/er-emergencies_ERisforEmergenciesSevenPractices.pdf on January 21, 2016.
51 Pines J, Schlicher N, Presser E, George M, McClellan M. Washington State Medicaid: Implementation and Impact of “ER is for Emergencies” Program. The Brookings Institution. May 4, 2015. Accessed at http://www.brookings.edu/~/media/Research/Files/Papers/2015/05/04- emergency-medicine/050415EmerMedCaseStudyWash.pdf?la=en on January 21, 2016.
52 Ku L and Broaddus M. Public and Private Health Insurance: Stacking Up the Costs. Health Aff. 2008;27(4):w318-w327. Accessed at http://content.healthaffairs.org/content/27/4/w318.full on May 5, 2014.
53 DiJulio B, Firth J, and Brodie M. Kaiser Health tracking Poll: April 2015. Kaiser Family Foundation. April 21, 2015. Accessed at http://kff.org/health-reform/poll-finding/kaiser-health-tracking- poll-april-2015/ on April 24, 2015.
54 Saloner B, Sabik L, Sommers BD. Pinching the Poor? Medicaid Cost Sharing under the ACA. N Engl J Med. 2014;370:1177-1180. Accessed at http://www.nejm.org/doi/full/10.1056/NEJMp1316370 on April 24, 2015.
16 10/12/2018 Page 139 Medicaid Expansion: Premium Assistance and Other Options
55 Congressional Budget Office. Offsetting Effects of Prescription Drug Use on Medicare’s Spending for Medical Services. November 2012. Accessed at https://www.cbo.gov/publication/43741 on May 6, 2015.
56 RAND Corporation. Cutting Drug Copayments for Sicker Patients Can Cut Hospitalizations and Save Money. January 11, 2006. Accessed at http://www.rand.org/news/press/2006/01/11.html on April 28. 2015.
57 Kaiser Commission on Medicaid and the Uninsured. Are Uninsured Adults Who Could Gain Medicaid Coverage Working? February 2015. Accessed at http://files.kff.org/attachment/fact- sheet-are-uninsured-adults-who-could-gain-medicaid-coverage-working on October 8, 2015.
58 Giammarise K. Corbett changes course on Medicaid. Pittsburgh Post-Gazette. March 6, 2014. Accessed at http://www.post-gazette.com/news/politics-state/2014/03/06/Gov-Corbett-backs- down-on-work-search-requirement/stories/201403060288 on May 5, 2014.
59 Corbett T. Letter to Secretary Kathleen Sebelius: Healthy Pennsylvania 1115 Demonstration Application. February 2014. Accessed at http://www.dpw.state.pa.us/cs/groups/webcontent/ documents/document/c_071204.pdf on May 5, 2014
60 Graham JR. How to Get a Medicaid Work Requirement? Bundle It with Paul Ryan’s Opportunity Grants. National Center for Policy Analysis. January 12, 2015. Accessed at http://healthblog.ncpa.org/how-to-get-a-medicaid-work-requirement-bundle-it-with-paul- ryans-opportunity-grants/ on April 28, 2015.
61 Davis C. Medicaid Expansion Work Requirements. National Health Law Program. October 4, 2013. Accessed at http://www.healthlaw.org/issues/medicaid/medicaid-expansion-toolbox/Medicaid- expansion-work#.VT_IKJOVkg4 on April 28, 2015.
62 Baicker K, Cutler D, Song Z. Workplace Wellness Programs Can Generate Savings. Health Affairs. 2010; 29(2):304-311. Accessed at http://content.healthaffairs.org/content/29/2/304.full on February 19, 2016.
63 American College of Physicians. Controlling Health Care Costs While Promoting the Best Possible Health Outcomes. Philadelphia: American College of Physicians; 2009: Policy Monograph.
64 American College of Physicians. Ethical Considerations for the Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid and Beyond. Philadelphia: American College of Physicians; 2010: Position Paper.
65 Lovelady J. Iowa Health and Wellness Plan. Iowa Department of Health and Human Services. Presentation. February 3, 2015. Accessed at https://www.legis.iowa.gov/docs/publications/SD/632296.pdf on May 5, 2015.
66 Alker J. Early returns from Iowa’s Health and Wellness Plan: Are Healthy Behaviors Working? Gerogetown University Health Policy Institute Center for Children and Families. February 20, 2015. Accessed at http://ccf.georgetown.edu/all/early-returns-iowas-health-wellness-plan-healthy- behavior-programs-working/ on May 5, 2015.
17 10/12/2018 Page 140 Product # 510160010 10/12/2018 Page 141 GOV5006 18-207
Uninsured Payment Protection
Submitted by: MSV Medical Student Section/ Jon Taylor-Fishwick
WHEREAS, many hospitals partake in cost shifting by increasing chargemaster lists prices disproportionally compared to the rates reimbursed by insurance companies, and
WHEREAS, uninsured patients in Virginia seeking emergent and non-emergent care are required to pay the chargemaster costs set by hospitals, and
WHEREAS, in 2016, three in ten uninsured, nonelderly adults were reported to be paying off at least one medical bill with medical debt attributed to 52% of all debt collections and almost half of all U.S. bankruptcies1, and
WHEREAS, the state of New Jersey has passed legislation requiring hospitals to charge uninsured patients no more than 115% the cost of Medicare payment rate for inpatient and outpatient services2, therefore be it
RESOLVED, the Medical Society of Virginia acknowledges the deleterious financial impact that cost shifting in hospitals can have on uninsured patients and support the development of a Medicare based fee-schedule for uninsured patients receiving inpatient and outpatient care.
1 https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/ 2Assembly Bill No. 2609 https://www.njleg.state.nj.us/2008/Bills/A3000/2609_I1.PDF
10/12/2018 Page 142 Staff Analysis – Resolution 18-207: Uninsured Payment Protection Submitted by the MSV Medical Student Section/ Jon Taylor-Fishwick
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
Raise perceived 10.3.15- Low Cost Insurance Benefits: Staff recommends this A chargemaster is the list of billable value of physicians Product resolution be not adopted. services by a hospital and/or provide. Date: 11/8/1997 Would help lower
The Medical Society of Virginia patients’ out of pocket While the intent of this These prices may not represent actual supports the concept of a low cost costs resolution is admirable, cost and/or negotiated cost of the health insurance product and MSV has traditionally services. continued efforts in pursuing a low opposed a Medicare May ensure that cost insurance product to be based fee schedule for Uninsured patients seeking care may uninsured patients are available for uninsured Virginians, most services, as it usually receive a bill for the full amount of a not charged more than low income workers, and small represents a significant service. insured patients businesses. deficit from the actual cost
Reaffirmed 10/28/2007 to provide care. For care delivered to individuals at or Reaffirmed 10/22/2017 less than 200% of federal poverty Drawbacks: MSV should continue to level, charity care provisions may work with policymakers to apply. May in some cases ensure that the uninsured increase some have access to affordable Hospitals are required to post their patients out of pocket insurance and that out of financial assistance policies in Virginia. costs pocket costs do not
interfere with an This resolution asks MSV to support a May negatively impact individual’s ability to Medicare based fee schedule for commercial fee access needed medical uninsured patients. schedules services.
10/12/2018 Page 143 18-208
Investigation into Healthcare Insurance Copay Accumulator Programs
Submitted by: Richmond Academy of Medicine
WHEREAS, the use of high cost specialty drugs is becoming more commonplace in everyday medical practice, and
WHEREAS, a large portion of these costs are often applied to the patient’s deductible, copay, coinsurance or maximum out of pocket payments, and
WHEREAS, more and more patients are subject to increasingly high-deductible insurance plans, and
WHEREAS, many pharmaceutical manufacturers have provided patients with copay or coupon assistance programs to cover the patient’s portion of these expenses, and
WHEREAS, many healthcare insurance companies have sought to shift the burden of these costs for high cost specialty drugs, back to the patient and the pharmaceutical manufacturer, and
WHEREAS, many healthcare insurance companies have initiated Copay Accumulator Programs, within their insurance products, to avoid the benefit of the pharmaceutical manufacturer’s copay assistance program from covering the patient’s deductible, copay, coinsurance or maximum, out of pocket payments, and
WHEREAS, many patients with chronic and rare diseases are vulnerable and depend on copayment assistance programs for their specialty medications. This new practice of copay accumulator adjustment, coupled with the rise of high deductible health plans and coinsurance, makes it difficult, if not impossible, for patients to adhere to their treatment plan, and
WHEREAS, additionally, it is concerning that many of these plan changes have been implemented with little to no notification to the member. For those patients that do receive notification, the language can be difficult to understand, even for the most seasoned of healthcare experts, and
WHEREAS, in many cases, there are only a few therapies available to treat patients with a chronic or rare condition, and it is incredibly unlikely that those few therapies have a therapeutically equivalent alternative. In the absence of copayment assistance, these individuals are often unable to afford their treatment. Biologics and other specialty therapies are often the only option for effectively treating these diseases, making affordability and access to these therapies critical, and
WHEREAS, the Medical Society of Virginia, is deeply concerned about the issues mentioned above and the risks they pose to many patients with chronic and rare diseases, therefore be it
RESOLVED, the Medical Society of Virginia urge the Virginia State Corporation Commission Bureau of Insurance to undertake an investigation into Healthcare Insurance Co-pay Accumulator programs to ensure patients can afford their medications.
10/12/2018 Page 144 Staff Analysis – Resolution 18-208: Investigation into Healthcare Insurance Copay Accumulator Programs. Submitted by Richmond Academy of Medicine
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
The resolution asks MSV to urge Empower .No existing policy Benefits Staff recommends this resolution be the Virginia State Corporation physicians to Patients would benefit adopted as amended. Commission Bureau of Insurance manage from state oversight as to undertake an investigation into change reforms would likely Accumulator programs place an Healthcare Insurance Co-pay increase their ability to unjustified burden on patients who Accumulator programs to ensure pay for prescriptions and have insurance by placing a barrier to patients can afford their actually be able to use reaching their deductible to be able to medications. their insurance benefits apply their insurance benefits. by reaching their Many patients with high deductible. By affording Staff suggests adding a resolved deductible plans are still unable their medications, clause clarifying the MSV’s position to pay for their prescriptions. patients will experience regarding Copay Accumulator Pharmaceutical companies often improved health Programs: offer coupons to reduce the outcomes. prescription cost. In the past, the RESOLVED, the Medical Society of value of these coupons has been Physicians would be able Virginia opposes copay accumulator applied toward a patient’s to better treat patients programs or any program that does not deductible.i who are able to afford apply all patient payments toward their prescriptions. deductibles and out of pocket A new program, referred to as maximums. co-pay accumulator adjustment Drawbacks programs, is no longer counting Insurance companies RESOLVED, the Medical Society of copay coupons toward patient would likely push any Virginia urge the Virginia State deductibles and out-of-pocket costs toward the patients Corporation Commission Bureau of maximums. This makes it in other ways Insurance to undertake an difficult for patients to ever reach investigation into Healthcare Insurance their deductible and enjoy their Co-pay Accumulator programs to insurance benefits.ii ensure patients can afford their medications. Many PBMs (Express Scripts and CVS Caremark), insurers (United Healthcare, Molina, and BlueCross BluesShield of Texas and Illinois), and large companies (Walmart, Home Depot, and Allstate) have started to use these co-pay accumulator programs.iii
10/12/2018 Page 145 i https://www.healthaffairs.org/do/10.1377/hblog20180824.55133/full/ ii https://www.healthaffairs.org/do/10.1377/hblog20180824.55133/full/ iii https://www.healthaffairs.org/do/10.1377/hblog20180824.55133/full/
10/12/2018 Page 146 18-209
Establishment of a Reinsurance Program
Submitted by: Richmond Academy of Medicine
WHEREAS, the Federal government has sought to undermine the Affordable Care Act by eliminating the individual mandate, refusing to support the cost sharing reduction payments, withdrawing funds for promotion of the Health Insurance Exchange, as well as limited the open enrollment period, and
WHEREAS, all of these factors have caused instability in the individual and small group marketplace for healthcare insurance, and
WHEREAS, this has contributed to rising premiums and withdrawal of insurance carriers from this market, and
WHEREAS, there has been bipartisan support in the US Congress for establishment of a reinsurance program to help with this situation, and
WHEREAS, several other states, most recently Maryland, have successfully passed legislation to help improve the individual and small group marketplace. They have also sought to bring back the individual mandate at the state level and have restricted the use of non-ACA compliant or short-term insurance policies, therefore be it
RESOLVED, that the Medical Society of Virginia work to bring additional insurance carriers into the individual and small group marketplace, in addition to creating a more favorable environment for lower premiums and coverage of persons with costly medical issues.
10/12/2018 Page 147 Staff Analysis – Resolution 18-209: Establishment of a Reinsurance Program. Submitted by Richmond Academy of Medicine
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
Reinsurance programs help Empower 10.3.18- Withdrawal of Benefits Staff recommends this resolution be insurers cover medical claims physicians to Insurance Providers from Patients with increased adopted. above a certain amount. This manage the ACA and Individual opportunities to purchase reduces risk to the insurance change Marketplace low cost, quality Reinsurance programs are a good first company, allowing them to lower Date: 10/22/2017 healthcare will have a step to ensuring stability to Virginia’s premiums. The federal better opportunity to insurance marketplace. government in turn has lower The Medical Society of access healthcare and premium subsidies, the savings Virginia will propose policy have improved health of which are passed to the states changes which will require outcomes to help pay for the reinsurance health plans program. Lower premiums participating in the Physicians will better be encourage patients who Commonwealth of Virginia able to provide previously dropped their State Benefits Program to healthcare to patients insurance to return to the market, also provide individual who can afford care, thereby increasing enrollment coverage for the public at leading to better health and potentially improving the large in the regions in outcomes insurance risk pooli which they participate, and be it further that these States can apply for a 1332 state individual policies must be Drawbacks innovation waiver through CMS commensurate with what Reinsurance programs to establish reinsurance the plans offer to state have a state fiscal cost programs. Six states have employees including which is likely to increase received the waiver: Alaska, benefits, premiums and over time Maine, Minnesota, New Jersey, administrative expenses. Oregon, Wisconsin, and Marylandii
Maryland adopted a reinsurance program in 2018iii Results: o Estimated increased 5% enrollment in 2019 o 17% rate decrease for CareFirst Blue Cross and Blue Shield’s HMO plan (Prior to reinsurance, CareFirst had requested to increase rates by 18.5%) o 11.1% rate decrease for
10/12/2018 Page 148 CareFirst’s two PPO plans (prior to reinsurance, rates would have risen 91%) o 7.4% rate decrease for Kaiser’s HMO coverage (Kaiser first asked to raise rate by 37.4% before reinsurance)
Causes of insurance rate increases include: zeroed-out individual insurance mandate, expansion of minimal short-term plans, and lower enrollmentiv
i http://www.modernhealthcare.com/article/20180921/NEWS/180929959 ii http://www.modernhealthcare.com/article/20180921/NEWS/180929959 iii http://www.modernhealthcare.com/article/20180921/NEWS/180929959 iv http://www.modernhealthcare.com/article/20180921/NEWS/180929959
10/12/2018 Page 149 18-210
Improve the Insurance Claims Process
Submitted by: Richmond Academy of Medicine
WHEREAS, insurers impose deadlines on when physicians may submit a bill and if a bill is submitted after this date it will not be paid, and
WHEREAS, on the other hand, pre-authorized procedures patients have had completed can be denied by insurers year later, and
WHEREAS, there seems to be no statute of limitation on when insurers can do a review and reverse a coverage decision for care the patient/family thought was long since covered, therefore be it
RESOLVED, the Medical Society of Virginia support the implementation of a mandatory deadline of no less than twelve months from the date of service for physicians to submit claims; and further be it
RESOLVED, the Medical Society of Virginia support requiring insurers to add a minimum of 30 days to the submission deadline every time they kick a claim back to a physician for any reason, and be it further
RESOLVED, that the Medical Society of Virginia support enforcement of coverage for pre-authorized services by insurance companies and prevents later reversal of already granted pre- authorization.
10/12/2018 Page 150 Staff Analysis – Resolution 18-210: Improve the Insurance Claims Process. Submitted by Richmond Academy of Medicine
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients 10.10.03- Improve Step This resolution asks the MSV to Empower Therapy in Virginia Benefits Staff recommends adopting the support expanding the timelines for physicians to Removing retroactive resolution as two separate policies: 1) which insurance companies must manage denials would remove bill submission timelines and 2) accept a bill, requiring insurance change 10.10.04- Improve Upon barriers to patients retroactive prior authorization denials. companies to add 30 days to the the Current Prior receiving treatment and aforementioned submission deadline Authorization Law in the reduce the time and cost Policy 1: Bill Submission Timelines if the insurance company returns the State of Virginia of resubmitting for the claim to the physician, and banning same process twice. RESOLVED, the Medical Society of retroactive denials of previously Virginia support the implementation of approved prior authorizations. 10.10.05- Opposing Drawbacks a mandatory deadline of no less than Health Plans Restricting None twelve months from the date of service Bill Submission Timelines Medically Necessary for physicians to submit claims; and Virginia does not require Care further be it insurance companies to accept bills according to a specified See next page for policies RESOLVED, the Medical Society of timeline Virginia support requiring insurers to For prior authorization cases, add a minimum of 30 days to the insurance companies are submission deadline every time they required to respond within 24 kick a claim back to a physician for any hours for urgent or 2 business reason, and be it further days for non-urgent cases.i Policy 2: Prior Authorization Retroactive Prior Authorization Retroactive Denials Denials Virginia does not ban retroactive RESOLVED, that the Medical denial of approved servicesii Society of Virginia support enforcement of coverage for pre- Virginia does require a prior authorized services by insurance authorization granted by another companies and prevents later reversal plan to be honored for at least of already granted pre-authorization. the initial 30 days of a member’s new prescription coverageiii
12 states do have a law regarding retroactive denials (see next page for summary)iv
10/12/2018 Page 151 Summary of States with Prior Authorization Retroactive Denial Lawsv
Alaska- No retroactive denial for approved medical procedure (medical necessity) unless PA is based on materially incomplete or inaccurate information Arizona- Plan cannot rescind or modify the authorization after the provider renders the authorized care in good faith and pursuant to the authorization. Arkansas- Plan cannot rescind or modify the authorization after the provider renders the authorized care in good faith and pursuant to the authorization Delaware- o Plan cannot revoke, limit, condition or restrict a PA on ground of medical necessity after the date the health care provider received the PA but before delivery of service o A PA for a health care service shall be valid for a period of time that is reasonable and customary for the specific service, but no less than 60 days from the date the health care provider receives the PA, subject to confirmation of continued coverage and eligibility and to policy changes validly delivered Idaho- Approval of covered service cannot be rescinded after the service is provided, except for fraud/misrepresentation/nonpayment of premium, exhaustion of benefits, or member not enrolled at the time service was provided Illinois- Approval of medical exception request good for one year or end of coverage New York- Plan must pay claims for a service for which a PA was received prior to the rendering of service, unless the enrollee was not a covered person at the time of care, the submission was not timely under the provider’s contract, materially inaccurate info submitted, fraud took place, or care related to pre- existing condition that was excluded from coverage North Carolina- Insurer cannot retract its determination after the services, supplies, or other items have been provided, or reduce payments for a service, supply, or other item furnished in reliance on the determination, unless it was based on a material misrepresentation about the insured's health condition that was knowingly made by the insured or the provider. N.C. Gen. Stat. 58-3- 200(c). Ohio- For PAs related to drugs for chronic conditions, plan must honor PA for the lesser of 12 months from approval or the last day of eligibility. No retroactive denials of a PA assuming medical necessity and eligibility requirement met. Rhode Island- A plan cannot retrospectively deny a PA for health care services provided when PA has been obtained unless the approval was based on inaccurate info material to the review or the health care services were not provided consistent with the provider’s submitted plan of care and/or any restriction included in the PA granted by the review agent Tennessee- Initial determinations must follow written clinical criteria set out in statute. Decision within 30 days or 48 hours (expedited appeal) Washington- PA cannot expire sooner than 45 days from date of approval
MSV Policy
10.10.03- Improve Step Therapy in Virginia Date: 10/22/2017
The Medical Society of Virginia will work with stakeholders to reform step therapy in Virginia to require health plans, pharmacy benefit managers (PBMs) and other entities involved to cite clinical review data as justification for denials, create a uniform and expedited appeals and exception process, and establish a process for patients who transition from one insurance plan to another.
10.10.04- Improve Upon the Current Prior Authorization Law in the State of Virginia Date: 10/22/2017 The Medical Society of Virginia will continue to work with Insurers and request they be more open and transparent about their approval (and rejection) processes and insist that they release information identifying the common evidence-based parameters for insurers’ approval of the 10 most frequently prescribed chronic disease management prescription drugs, as required by the 2015 law § 38.2-3407.15:2.,
10/12/2018 Page 152 and be it further that the Medical Society of Virginia, work to require insurance companies, pharmacy benefit managers (PBM’s) and other entities involved to upgrade the electronic approval of prescription requests, which has been shown to bring cost savings in other states within a few years of its implementation, and be it further that the Medical Society of Virginia join the American Medical Association to aid in prior authorization reform with a goal of building a dialogue between providers, health plans and their third parties eliminate needless administrative waste from the system.
10.10.05- Opposing Health Plans Restricting Medically Necessary Care Date: 10/22/2017
The Medical Society of Virginia opposes any health plan mechanism that interferes in the timely delivery of medically necessary care, therefore be it further
The Medical Society of Virginia supports requiring health plans to provide physicians with real time access to covered benefits, the criteria for “medical necessity” and cost information so that physicians and their patients may work together to choose the most cost-effective medically appropriate treatment for patient care.
i https://www.ama-assn.org/sites/default/files/media-browser/public/arc-public/pa-state-chart.pdf ii https://www.ama-assn.org/sites/default/files/media-browser/public/arc-public/pa-state-chart.pdf iii http://lis.virginia.gov/cgi-bin/legp604.exe?151+ful+CHAP0516 iv https://www.ama-assn.org/sites/default/files/media-browser/public/arc-public/pa-state-chart.pdf v https://www.ama-assn.org/sites/default/files/media-browser/public/arc-public/pa-state-chart.pdf
10/12/2018 Page 153 18-211
Regulate and License Pharmacy Benefit Managers Who Serve Virginians
Submitted by: Richmond Academy of Medicine
WHEREAS, current prices for pharmaceuticals are rising more quickly than other health care costs, and
WHEREAS, rising insurance premiums, pharmaceutical copays, and out-of-pocket costs often result in the patient/consumer not being able to adhere to proposed treatment plans, and
WHEREAS, Pharmacy Benefit Managers (PBMs) currently determine the content of most formularies for health care plans and companies providing health care within the Commonwealth of Virginia, and
WHEREAS, PBMs also provide the majority of all pharmacy claim processing services, including but not be limited to negotiating drug prices, processing and adjudicating prescription requests, contracting with pharmacists or pharmacies, maintain pharmacy benefits networks, receiving payments for pharmacist services, making payments to pharmacists, negotiating, disbursing or distributing rebates, and handling all appeals, and
WHEREAS, PBM use of restricted formularies, prior authorization, utilization review and step therapy protocols are resulting in the disruption of the physician-patient relationship and interference in the agreed upon individualized treatment care plans, and
WHEREAS, PBM contracts with local pharmacies often result in limiting the pharmacist’s scope of care or ability to provide pharmacist services, thereby frequently resulting in increased costs to patients/consumers, and
WHEREAS, all PBM activities are not currently licensed or regulated by the Virginia Insurance Commissioner, therefore be it
RESOLVED, that the Medical Society of Virginia, in concert and collaboration with local and specialty physician organizations, pharmacist organizations, patient organizations and any other interested and affected parties work to ensure that the Virginia Insurance Commissioner has authority to appropriately oversee the actions of PBMs providing services to Virginians similar to the recently enacted Arkansas legislation (HB 1010) so PBM's are brought under oversight and held accountable for their actions in the pricing, management and dispensing of medications to Virginians.
10/12/2018 Page 154 Staff Analysis – Resolution 18-211: Regulate and License Pharmacy Benefit Managers Who Serve Virginians. Submitted by Richmond Academy of Medicine
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients 10.10.03- Improve Step Empower Benefits Staff recommends this resolution be The Virginia Insurance Therapy in Virginia Commissioner currently does not physicians to State oversight of PBMs adopted
manage have oversight over pharmacy 10.10.04- Improve Upon could shed light on any change benefit managers (PBMs) not the Current Prior practices that lead to headquartered in Virginia Authorization Law in the higher cost and State of Virginia administrative burden on both patients and Arkansas recently enacted physicians HB1010, which requires PBMs to
be licensed under the Arkansas See next page for policies Insurance Department, giving Drawbacks Arkansas oversight over PBMs Oversight of PBMs may operating in the state, regardless discourage PBM of headquarter locationi participation in Virginia and therefore decrease Pharmacy benefit managers are access for some patients. a key player, along with insurance companies and pharmaceutical companies, in the cost and availability of prescriptionsii iii
This resolution asks MSV to support efforts to better regulate PBMs that operate within Virginia.
10/12/2018 Page 155 10.10.03- Improve Step Therapy in Virginia Date: 10/22/2017
The Medical Society of Virginia will work with stakeholders to reform step therapy in Virginia to require health plans, pharmacy benefit managers (PBMs) and other entities involved to cite clinical review data as justification for denials, create a uniform and expedited appeals and exception process, and establish a process for patients who transition from one insurance plan to another.
10.10.04- Improve Upon the Current Prior Authorization Law in the State of Virginia Date: 10/22/2017 The Medical Society of Virginia will continue to work with Insurers and request they be more open and transparent about their approval (and rejection) processes and insist that they release information identifying the common evidence-based parameters for insurers’ approval of the 10 most frequently prescribed chronic disease management prescription drugs, as required by the 2015 law § 38.2-3407.15:2., and be it further that the Medical Society of Virginia, work to require insurance companies, pharmacy benefit managers (PBM’s) and other entities involved to upgrade the electronic approval of prescription requests, which has been shown to bring cost savings in other states within a few years of its implementation, and be it further that the Medical Society of Virginia join the American Medical Association to aid in prior authorization reform with a goal of building a dialogue between providers, health plans and their third parties eliminate needless administrative waste from the system.
i https://www.the-rheumatologist.org/article/arkansas-pbm-bill-step-right-direction/ ii https://www.sciencedirect.com/science/article/pii/S0002870318302485?via%3Dihub iii https://www.pbs.org/newshour/health/why-a-patient-paid-a-285-copay-for-a-40- drug?utm_campaign=KHN:%20Daily%20Health%20Policy%20Report&utm_source=hs_email&utm_medium=email&utm_content=65307958&_hsenc=p2ANqtz- 8oduiP-EzshPyMCBnkAb4ca42uLNN7YOa7hfUEPPwMjS5BIn7tYrGBlMAeTMTCpkpPClCiEh-37N_WAL8Rpc7fzAhvzQ&_hsmi=65307958
10/12/2018 Page 156 18-301 Nutrition Submitted by: MSV 2nd District
WHEREAS, diet is the single most significant risk factor for disability and premature death1, and
WHEREAS, most Americans do not adhere to U.S. dietary recommendations2, and are exposed to marketing, food culture, lack of information of good nutritional choices and health impacts, and in some areas, food “deserts” with lack of healthy nutritional choices, and
WHEREAS, while schools are working toward helping children have better nutrition, there are still are some areas where poor nutritional items are available to children who may not make wise nutritional choices (including but not limited to items specifically recommended for avoidance in the daily diet of children, such as sodas, high sugar fruit juices and “sports” drinks, caffeinated products, candy, ice cream, and high fat processed meats), and
WHEREAS, the current state regulations, designed to conform with the FDA guidelines to provide vending products that must meet the guidelines for school meals exclude beverages from meeting any nutritional guidelines5, and
WHEREAS, diabetes has been declared a non-contagious epidemic of world-wide significance by the WHO4, and
WHEREAS, the MSV does not currently have in our guiding positions any specific statements regarding nutrition as an important and necessary part of the role physicians have in the total health of our patients and of the population of Virginia, and the necessary role as advocates for good nutritional practices where encouraged via education, guidelines, local or state regulations, be it therefore
RESOLVED, the MSV shall be engaged to encourage currently scientifically sound nutritional guidelines be advocated for in all spheres for the citizens of the Commonwealth of Virginia and, when able, serve as an advocate for the availability of food and beverages that are nutritionally healthy, particularly for the young or underserved, and be it further
RESOLVED, the MSV will serve as an advocate for education and, when able, provide support for efforts to improve nutritional patterns and eating habits to effect population health change.
10/12/2018 Page 157 References:
1. Devries S, Dalen JE, Eisenberg DM, et al. A deficiency of nutrition education in medical training. Am J Med . 2014;127(9):804–806.
2. U.S. Department of Agriculture. A snapshot of the 2015–2020 Dietary Guidelines for Americans. December 22, 2016. https://www.choosemyplate.gov/snapshot-2015-2020-dietary-guidelines-americans. Accessed August 7, 2018.
3. Locke, Amy MD;, Schneiderhan, Amy , MD;. Zick, Suzanna, ND, MPH, Am Fam Physician. 2018 Jun 1;97(11):721-728.
4. WHO global report on diabetes. http://www.who.int/diabetes/global-report/en/ Accessed August 7, 2018.
5. https://law.lis.virginia.gov/vacode/title22.1/chapter13/section22.1-207.4/ Accessed August 7, 2018
10/12/2018 Page 158 Staff Analysis – Resolution 18-301: Nutrition. Submitted by MSV 2nd District
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
The resolution asks MSV to Raise 10.1.15- Improve Obesity Benefits Staff recommends this resolution be support and advocate for perceived value Medicare & Insurance Patients will benefit from adopted. improved nutrition efforts in of physicians Coverage improved programming Virginia Date: 10/22/2017 and education related to Supporting scientifically sound The Medical Society of nutrition and may benefit nutritional guidelines is an opportunity The Virginia Department of Virginia through its from positive health for physicians to promote public health Education and the U.S. delegation to the AMA outcomes as a result endeavors. Department of Agriculture have supports coverage for several programs and initiatives healthcare costs Physicians will engage in related to child nutrition, associated with medical, a public health effort includingi: surgical, nutritional and affecting patients across o Virginia Direct behavioral treatment the state Certification with interventions for patients Medicaid Demonstration diagnosed with obesity. Project, National School Drawbacks Lunch Program, School 40.10.02- Eradicating Insurance and Breakfast Program, Food Deserts and Food administrative-imposed Afterschool Snack Insecurity appointment time limits Program, Fresh Fruit and Date: 10/25/2015 may minimize the time Vegetable Program, The Medical Society of available for physicians to Summer Food Service Virginia (MSV) supports speak with patients about Program efforts to reduce or nutrition eliminate food deserts and food insecurity in Virginia.
i http://www.doe.virginia.gov/support/nutrition/programs/index.shtml
10/12/2018 Page 159 18-302
Prohibiting Conversion Therapy in Those Under Age 18
Submitted by: MSV Medical Student Section
WHEREAS, conversion therapy, which aims to change a person’s sexual orientation, has no substantial evidence-based research which demonstrates its efficacy at reducing same- sex attraction or increasing other-sex attraction1, and
WHEREAS, as of January 2018, almost 350,000 adolescents have received conversion therapy and an estimated 20,000 more current adolescents will receive conversion therapy from a licensed health care professional before age 182, and
WHEREAS, homosexuality is not a mental disorder and was removed from the Diagnostic and Statistical Manual in 19733, and
WHEREAS, the American Psychiatric Association has shown that conversion therapy increases the risk of depression, guilt, helplessness, suicidality, substance abuse, and high risk sexual behaviors, among others, in LGBTQ youth4, and
WHEREAS, numerous medical societies, including the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, American College of Physicians, American Medical Association, and American Psychiatric Association oppose the use of conversion therapy5, and
WHEREAS, as of October 2018, 13 states (New Jersey, California, Oregon, Illinois, Vermont, New Mexico, Connecticut, Rhode Island, Nevada, Washington, Hawaii, Delaware, and Maryland) and the District of Columbia have banned the use of conversion therapy by licensed professionals for those under age 186, therefore be it
RESOLVED, that the MSV oppose the use of conversion therapy or any similar practice, including but not limited to reparative therapy, ex-gay therapy, or sexual orientation change efforts, in those under age 18 by health care providers, and let it be further
RESOLVED, that the MSV support legislation that bans conversion therapy use, and let it be further
RESOLVED, that the MSV advocate for resources aimed at supporting LGBTQ youth to promote self and social acceptance.
1 https://www.hrc.org/resources/the-lies-and-dangers-of-reparative-therapy 2 https://williamsinstitute.law.ucla.edu/wp-content/uploads/Conversion-Therapy-LGBT-Youth-Jan-2018.pdf 3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4695779/ 4 http://www.nclrights.org/bornperfect-laws-legislation-by-state/ 5 https://www.hrc.org/resources/policy-and-position-statements-on-conversion-therapy 6 http://www.nclrights.org/bornperfect-laws-legislation-by-state/
10/12/2018 Page 160 Staff Analysis – Resolution 18-302: Prohibiting Conversion Therapy in Those Under Age 18. Submitted by MSV Medical Student Section
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
“Conversion therapies” (or Empower n/a Benefits: Staff recommends amending and “reparative therapies”) are physicians to adopting the resolution. defined as therapy aiming at manage Minor patients will benefit changing the sexual orientation change from enhanced patient Staff recommends removing the of lesbian women and gay meni protections second resolved clause that references legislative action to remove Conversion therapy is not a technical redundancy. The first evidence-based and has Drawbacks: resolved clause is adequate to guide demonstrated negative effects on the legislative team to oppose participantsii There are no drawbacks, legislation. as conversion therapy is Many physician organizations harmful to patients and RESOLVED, that the MSV oppose oppose the use of conversion not considered an the use of conversion therapy or any therapy, including: the American evidence-based practice similar practice, including but not Academy of Pediatricsiii, limited to reparative therapy, ex-gay American Academy of Child and therapy, or sexual orientation change Adolescent Psychiatryiv, efforts, in those under age 18 by health American College of Physiciansv, care providers, and let it be further American Medical Associationvi, and American Psychiatric RESOLVED, that the MSV support Associationvii legislation that bans conversion therapy use, and let it be further 13 states ban the use of conversion therapy by licensed RESOLVED, that the MSV advocate professionals for those under age for resources aimed at supporting 18viii LGBTQ youth to promote self and social acceptance. During Virginia’s 2018 General Assembly session Sen. Surovell introduced SB 245, which prohibited licensed health care providers to engage in conversion therapy with any person under 18 years old. Although it did not pass, similar bills are expected in 2019.
10/12/2018 Page 161 i http://annals.org/aim/fullarticle/2292051/lesbian-gay-bisexual-transgender-health-disparities-executive-summary-policy-position ii http://annals.org/aim/fullarticle/2292051/lesbian-gay-bisexual-transgender-health-disparities-executive-summary-policy-position iii http://pediatrics.aappublications.org/content/pediatrics/92/4/631.full.pdf iv https://www.aacap.org/AACAP/Policy_Statements/2018/Conversion_Therapy.aspx v http://annals.org/aim/fullarticle/2292051/lesbian-gay-bisexual-transgender-health-disparities-executive-summary-policy-position vi https://policysearch.ama-assn.org/policyfinder/detail/conversion%20therapy?uri=%2FAMADoc%2FHOD.xml-0-805.xml vii file:///C:/Users/JGalloway/Downloads/position-2000-therapies-change-sexual-orientation%20(2).pdf viii http://www.nclrights.org/bornperfect-laws-legislation-by-state/
10/12/2018 Page 162 18-303
Support Opioid Education in Virginia Public Schools
Submitted by: MSV Medical Student Section
WHEREAS, the number of fatal heroin and fentanyl overdoses in Virginia has steadily increased over the past 5 years, with an almost 6-fold total increase in number of deaths between 2011 to 20161, and
WHEREAS, President Trump and Governor Northam have declared the opioid crisis a Public Health Emergency2,3, and
WHEREAS, overdose education and naloxone distribution (OEND) programs implemented in Massachusetts, Baltimore, and New York resulted in decreased deaths from opioid overdose and were effective at improving knowledge and attitudes toward opioid overdose4,5,6, and
WHEREAS, no current statewide educational resources or standardized curriculum exists within the Virginia Department of Education regarding the opioid epidemic7, and
WHEREAS, the AMA Opioid Task Force encourages physicians to “enhance education and training” and “help end the stigma” of opioids8, therefore be it
RESOLVED, that the Medical Society of Virginia support the creation of statewide educational resources for Virginia public schools regarding the opioid crisis and opioid overdose, and be it further
RESOLVED, that the Medical Society of Virginia support Virginia public schools in establishing a curriculum to educate students on opioid overdose, including identifying symptoms of overdose, treating overdose, and providing support for victims of opioid abuse/overdose.
1 “Opioid Addiction.” Virginia Department of Health, 2018, www.vdh.virginia.gov/data/opioid-overdose/. https://www.whitehouse.gov/opioids/ 2 https://www.whitehouse.gov/opioids/ 3 https://www.governor.virginia.gov/newsroom/all-releases/2018/february/headline-822715-en.html 4 Heavey SC, Burstein G, Moore C, Homish GG. Overdose Education and Naloxone Distribution Program Attendees: Who Attends, What Do They Know, and How Do They Feel? J Public Health Manag Pract. 2018 Jan/Feb;24(1):63-68. https://www.ncbi.nlm.nih.gov/pubmed/28257406 5 Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013 Jan 30;346:f174. https://www.ncbi.nlm.nih.gov/pubmed/23372174 6 Lewis DA, Park JN, Vail L, et al. Evaluation of the Overdose Education and Naloxone Distribution Program of the Baltimore Student Harm Reduction Coalition. Am J Public Health. 2016 Jul;106(7):1243-6. https://www.ncbi.nlm.nih.gov/pubmed/27077351 7 http://www.doe.virginia.gov/support/prevention/drug_use/index.shtml 8 https://www.ama-assn.org/delivering-care/reversing-opioid-epidemic
10/12/2018 Page 163 Staff Analysis – Resolution 18-303: Support Opioid Education in Virginia Public Schools Submitted by MSV Medical Student Section
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
The resolution asks MSV to Raise 40.2.03- Benefits Staff recommends amending and support the creation of statewide perceived value Reporting/Substance Students will benefit from reaffirming policy 40.2.03 in lieu of opioid education resources for of physicians Abuse increased awareness of resolution 18-303: Virginia public schools and the Date: 11/5/1994 the risks and signs of development of a public school The Medical Society opioid addiction, as well 40.2.03- Reporting/Substance Abuse curriculum to education students supports educational as how to properly use Date: 11/5/1994 on the risks, symptoms, and how programs in Virginia’s naloxone to respond to opioid overdose. schools regarding Physicians could The Medical Society supports substance demonstrate leadership educational programs in Virginia’s The General Assembly passed abuse prevention. in the development of schools regarding substance HB 1532 in 2018, which Reaffirmed 11/7/2004 curricula abuse prevention. Such educational encourages school districts to Reaffirmed as amended programs should include curricula include age-appropriate 10/26/2014 Drawbacks specific to opioid addiction, specifically prescription drug education as With limited local school identifying symptoms of overdose, part of their mandated health 40.6.07- Health Education district budgets, utilizing treating overdose, and providing education. The law offers the in Schools existing statewide public support for persons experiencing School Board of the City of The Medical Society of education efforts, such as opioid misuse/overdose. Virginia Beach curricula as an Virginia supports Curb the Crisis and example.i comprehensive clinical REVIVE, may be a more evidence-based health fiscally viable option Reaffirmed 11/7/2004 The Virginia state government education in Virginia. Reaffirmed as amended 10/26/2014 has an existing statewide public Amended by Substitution educational effort regarding 10/22/2017 opioids and overdose prevention called Curb the Crisis, as well as 40.2.01- Addiction in REVIVE, a public campaign for Children opioid overdose and naloxone Date: 11/11/1989 education for Virginia. The Medical Society of Virginia supports measures This educational effort is a to prevent addiction in collaborative among five Virginia children in the agencies: Department of Health, Commonwealth and in the Department of Behavioral Health Nation through the and Developmental Services, resources at its command. Department of Criminal Justice Reaffirmed 10/25/2009 Services, Department of Health Reaffirmed as amended Professions, and Department of 10/22/2017 Social Services
10/12/2018 Page 164
MSV participates on the Governor’s Task Force on Prescription Drug and Heroin Abuseii
As part of a statewide workgroup, Virginia schools of Medicine, Osteopathy, Pharmacy, Dentistry, Physician Assistants and Nursing are working to add opioid education to their curricula.
i https://pilotonline.com/news/government/virginia/article_c8059f1e-d3b6-53e4-8743-ce3a6d7e5e8d.html ii http://www.dhp.virginia.gov/taskforce/default.htm
10/12/2018 Page 165 18-304
Support Expanded Good Samaritan Overdose Immunity Laws
Submitted by: MSV Medical Student Section
WHEREAS, the number of fatal heroin and fentanyl overdoses in Virginia has steadily increased over the past 5 years, with an almost 6-fold increase in the number of deaths between 2011 to 20161, and
WHEREAS, current Virginia law (§ 18.2-251.03 Safe reporting of overdoses) allows for an affirmative defense to prosecution of an individual who, in good faith, seeks or obtains emergency medical attention for himself, if he is experiencing an overdose, or for another individual, if such other individual is experiencing an overdose2, and
WHEREAS, current Virginia law does not offer immunity from arrest following emergency reporting of overdose for themselves or another person, and
WHEREAS, the person reporting the overdose is subject to arrest when there is concomitant criminal offense related to the controlled substance, alcohol, or combination of such substances that resulted in the overdose, and
WHEREAS, there is precedence of good Samaritan laws related to arrest in circumstances of overdose reporting as seen in Maryland Senate Bill 654 – Criminal Procedure – Immunity – Alcohol- or Drug-Related Medical Emergencies approved by the governor, May 12, 20153, therefore be it
RESOLVED, that the Medical Society of Virginia amend its current policy 40.2.04 – “Good Samaritan” Protection for Overdose Witness as follows:
The Medical Society of Virginia supports granting “Good Samaritan” protection for those who call 9-1-1 when witnessing a possible drug overdose, including protection from arrest for persons reporting a possible overdose.
1 “Opioid Addiction.” Virginia Department of Health, 2018, www.vdh.virginia.gov/data/opioid-overdose/. 2 https://law.lis.virginia.gov/vacode/title18.2/chapter7/section18.2-251.03/ 3 https://bha.health.maryland.gov/OVERDOSE_PREVENTION/Documents/Maryland-2015-SB654- Chaptered.pdf
10/12/2018 Page 166 Staff Analysis – Resolution 18-304: Support Expanded Good Samaritan Overdose Immunity Laws Submitted by MSV Medical Student Section
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
The resolution asks MSV to Raise 15.2.03- Strengthen Good Benefits Staff recommends the resolution be amend its policy 40.4.04 “Good perceived value Samaritan Laws More patients adopted. Samaritan” Protection for of physicians Date: 10/30/1993 experiencing an overdose Overdose Witness to include The Medical Society of may receive medical While current law provides for an protection from arrest. Virginia supports legislation attention affirmative defense, an individual may requiring payment of court still be arrested. Removing barriers to As of July 15, 2017, 40 states, and attorney fees to a Drawbacks reporting overdose deaths may help including Virginia, and the District defendant who is named in Without support of the individuals access lifesaving of Columbia have passed an a lawsuit and subsequently law enforcement emergency services. overdose Good Samaritan law eliminated from the suit by community, changes to that provides some protection application of the Virginia the Good Samaritan law from arrest or prosecution for Good Samaritan Act. are unlikely and would individuals who report an Reaffirmed 10/28/2007 expend political capital overdose in good faithi Reaffirmed 10/22/2017
Virginia’s Good Samaritan overdose law (§ 18.2-251.03) provides a potential protection from prosecution (affirmative defense), but not protection from arrest.ii Such a person is required to remain at the scene and cooperate with emergency medical personnel and law enforcement.
23 states provide protection from arrestiii
Several bills introduced in Virginia over the past few years, including HB 596 in 2018, have not passed and have been met with strong opposition from law enforcement groups.
10/12/2018 Page 167 i https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf ii https://law.lis.virginia.gov/vacode/18.2-251.03 iii https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf
10/12/2018 Page 168 18-305
Expansion of Drug Take Back Programs
Submitted by: MSV Medical Student Section
WHEREAS, the FDA recommends the use of drug take-back programs to safely dispose of Medications1, and
WHEREAS, drug take-back programs are sanctioned by the DEA, including but not limited to take- back by law enforcement or any registrant authorized by the Administration2,3, and
WHEREAS, the DEA notes the presence of unused prescription as a public safety issue with the potential for accidental poisoning, misuse, and overdose4, and
WHEREAS, the DEA recognizes the potential of proper disposal of unused drugs to save lives and protect the environment4, and
WHEREAS, in 2015, 6.4 million Americans were reported to have abused controlled prescription drugs with the majority (53.7% of pain reliever misuse) coming from family and friends5, and
WHEREAS, given the current opioid crisis, the importance of safe disposal of medication is greater than ever, however Virginia currently only has a single state sponsored Drug Take-Back Day4, and
WHEREAS, many cities do not have a drug takeback location within a 30 miles radius5, and
WHEREAS, Virginia currently relies heavily on private pharmacies and corporations to supply a year- round drug take-back option6, therefore be it
RESOLVED, that the Medical Society of Virginia supports the expansion of Drug Take-Back programs, as well as increasing public awareness about the availability of such programs statewide.
1 "Disposal Of Unused Medicines: What You Should Know". 2018. Fda.Gov. https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedici nes/ucm186187.htm. 2 "PART 1317 - Subpart B - Disposal Of Controlled Substances Collected From Ultimate Users And Other Non-Registrants". 2018. Deadiversion.Usdoj.Gov. https://www.deadiversion.usdoj.gov/21cfr/cfr/1317/subpart_b.htm. 3 Federal Register / Vol. 77, No. 246 / Friday, December 21, 2012 / Proposed Rules https://www.gpo.gov/fdsys/pkg/FR-2012-12-21/pdf/2012-30699.pdf 4 Drug Enforcement Administration. “Take Back Day.” 2018. https://takebackday.dea.gov/ 5 SAMSHA. ”Prescription Drug Use and Misuse in the United States: Results from the 2015 National Survey on Drug Use and Health.” September 2016. https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR2-2015/NSDUH-FFR2-2015.htm 6 Controlled Substance Public Disposal Locations - Search Utility. (2018). Apps.deadiversion.usdoj.gov. https://apps.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e1s2https://apps.deadiversion.usdoj.gov/pubdispsearch/ spring/main?execution=e1s2
10/12/2018 Page 169 Staff Analysis – Resolution 18-305: Expansion of Drug Takeback Programs Submitted by MSV Medical Student Section
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients The resolution asks MSV to Raise None, but consistent with Benefits Staff recommends this resolution be support the expansion and perceived value the MSV Opioid Misuse By encouraging adopted. increased public awareness of of physicians Task Force additional takeback drug takeback programs. recommendations. programs, fewer opioid Promoting responsible methods for
pills would be available disposal of medication will ensure less Drug takeback programs offer “MSV will seek support for diversion medication is available for diversion. patients a place to dispense of unused medication, including for development of patient education opioids. Drawbacks materials that promote Takeback programs can Virginia takes part in a statewide proper be expensive and carry a Drug Take-Back Day as part of a use/disposal of safety risk nationwide U.S. Drug medications and that Enforcement Administration Take offer a ‘prescription’ for i Back Day. managing pain without medication.” Localities also operate drug take back programs, including as Roanoke Countyii
Some pharmacies also offer takeback programs, including CVS and local community pharmacies.
Budget constraints still place considerable limitations on both public and private drug takeback programs, with many communities still lacking access to a takeback program within close proximity. The DEA provides a searchable location database
10/12/2018 Page 170 i https://www.oag.state.va.us/programs-initiatives/drug-take-back-program ii https://www.roanokecountyva.gov/index.aspx?NID=1748
10/12/2018 Page 171 18-306
Address the Dangers of Head Trauma and Other Potential Injuries in Sports
Submitted by Richmond Academy of Medicine
WHEREAS, the literature clearly proves that head injuries, whether mild or severe, can have long term consequences on football players, and
WHEREAS, research increasingly shows a correlation between long-term brain disease and the age at which children begin playing tackle football, and
WHEREAS, medical professionals should educate the public adequately about the risks of traumatic brain injury to our children which can occur while playing football, therefore be it
RESOLVED, that the Medical Society of Virginia support requiring schools in the Commonwealth of Virginia to educate students and parents on the risks of participating in sports, including but not limited to brain injury, spinal cord injury, internal organ injuries, and broken bones.
10/12/2018 Page 172 Staff Analysis – Resolution 18-306: Address the Dangers of Head Trauma and other Potential Injuries in Sports Submitted by Richmond Academy of Medicine
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
The resolution asks MSV to Raise 40.6.07- Health Education Benefits Staff recommends this resolution be support requiring schools to perceived value in Schools By providing more not adopted. educate students and parents on of physicians The Medical Society of information, students and the risks of participating in sports. Virginia supports parents will have the Physicians should partner with their comprehensive clinical opportunity to make local school systems and patients to A recent study published in evidence-based health informed decisions educate them about the risks and JAMA linked football participation education in Virginia. regarding sports benefits of participation in sports. to brain injuries, including Amended by Substitution participation Chronic Traumatic 10/22/2017 Encephalopathy (CTE)i Drawbacks Schools have limited A 2017 Boston University found a resources to provide connection between youth education about sports football (under age 12) and later- participation risks. As life emotional and behavioral this information is impairment. Younger age was publically available, associated with worse clinical parents and students function.ii have other opportunities to learn about the risks
i https://jamanetwork.com/journals/jama/fullarticle/2645104 ii https://www.eurekalert.org/pub_releases/2017-09/buso-ssl091417.php
10/12/2018 Page 173 What if … FLAG BECOMES THE STANDARD WAY OF PLAYING FOOTBALL UNTIL HIGH SCHOOL? An Aspen Institute Sports & Society Program Analysis
10/12/2018 Page 174 What if … FLAG BECOMES THE STANDARD WAY OF PLAYING FOOTBALL About This Series, Paper UNTIL HIGH SCHOOL? Hosted by the Aspen Institute's Sports & Society Program, An Aspen Institute Sports & Society Program Analysis Future of Sports is a quarterly conversation series that aims to think through the biggest ideas at the intersection of sports and As the 2018 football season gets underway, a game that looms society. We convene thought large in our sports culture — and the American experience over leaders from diverse perspectives, the past century — very much sits at a crossroads. At the NFL and and ask, "What if ...?" The goal college level, the sport remains popular, as a gathering place in is to demystify and advance a fragmented society and a geyser of content consumed by fans, dialogue on paradigm shifts that gamblers, media and other corporations. But signs of erosion in could shape the future of sports. public support are emerging, and at the youth and high school levels participation rates are down as parents and children The inaugural event in the series, question the wisdom of strapping on a helmet. in January 2018, was on the future of football, where we posed the In 2017, the number of students playing high school football fell question, "What if flag football for the fourth consecutive year to 1.07 million, a one-year loss was the standard way of playing of 20,893 in an era when school-based participation in most 1 the game until high school?" The other sports continues to grow. One level down on community event drew major media attention fields, among children ages 6 to 12, regular participants last year and trended on social media. dipped to just under one million, a 17.4-percent decrease over the past five years.2 To further analyze the opportunity, the Sports & Society Some of that decline can be attributed to growing concerns over Program produced this white injuries, particularly those to the brain. In 2016, a UMass Lowell paper, co-authored by Tom Center for Public Opinion Research survey found that 78 percent Farrey, executive director, and of American adults do not think it is appropriate for children to Jon Solomon, editorial director, participate in tackle football before the age of 14, and that 63 both journalists who have percent believe it is either certainly or probably false that tackle 3 won national awards for their is a safe activity for children before they reach high school. coverage of football issues. Among those sounding the alarm are a growing number of NFL They can be reached at players, including legendary quarterback Brett Favre, who in June [email protected] and called tackle football unsafe for kids. In July, prominent football [email protected]. journalist Peter King added his voice, deeming tackle “not all that smart” in middle school, and possibly even high school. This, in For more on the Future of Sports the same year that Tom Brady, who didn’t play tackle football series: as.pn/FutureofSports until high school, led the New England Patriots to a Super Bowl championship game for the eighth time. The Sports & Society Program In the wake of medical research revealing the harm that can thanks Marilyn and Michael be caused by both concussions and repetitive subconcussive Glosserman for their generous hits to the head, state lawmakers in California,4 Illinois5, New support of the Future of Sports York, and Maryland6 this year introduced legislation proposing series. 10/12/2018 Page 175 minimum ages of 12 years or older for tackle football participation. Around the same time, the Concussion Legacy Foundation, a Boston- based brain trauma research and advocacy nonprofit, launched a public education program7 that urges parents to delay enrolling their children in tackle football before age 14 for health and safety reasons. Separately, a group of mothers whose sons played youth football and subsequently were diagnosed with chronic traumatic encephalopathy (CTE), a neurodegenerative disease linked to repetitive brain trauma, also is campaigning for children under 14 to eschew tackle for flag.8
Flag is a less violent variant of the game in which participants neither tackle nor collide with each other in order to advance and stop play, but instead attempt to grab detachable flags hanging from opponents’ waists. Advocates for delaying the starting age of tackle football argue that flag is a safer, age- appropriate alternative that reduces the risk of brain and other injuries while encouraging children to learn the sport’s fundamental skills and allowing them to enjoy the physical, emotional and social benefits of sports participation.
In homes and on fields across the U.S., this argument appears to be winning. Last year, in a little-noticed development, the game reached a significant milestone: Flag surpassed tackle as the most commonly played version of the game among kids ages 6 to 12 (3.3 percent played flag, 2.9 percent tackle), according to the Sports & Fitness Industry Association, which commissions an annual individual survey of participation in 120 sports and activities. Over the past three years, flag football participation in that age group is up 38.9 percent, more than any other team sport.
This white paper explores the consequences of this trend continuing, and asks: What if flag football becomes the standard way of playing the sport until high school? What are the implications for the sport, its stakeholders, and most importantly, the children who play the game?
We analyze this potential development from five angles:
• Public Health: Would delaying tackle football until high school make players safer?
• Youth Participation: Would flag bring more children into the sport, or drive them away?
• Friday Night Lights: What impact, if any, might there be on high school football?
• Football Industry: What could this mean for the NFL and college football, in terms of talent development, fan cultivation, and long-term bottom line?
• Civic Life: How would a shift to flag impact the values promoted through the sport? We peer into the crystal ball on these questions with the aid of a diverse set of experts convened in January at the Aspen Institute in Washington, D.C. The inaugural event in our Future of Sports conversation series, Future of Football: Reimagining the Game’s Pipeline (as.pn/FutureofFootball), featured panels that explored the above topics. The conversations were moderated by Sports & Society
10/12/2018 The Aspen Institute | SportsPage & Society176 Program 3 Program executive director Tom Farrey and panelists included Dr. Robert Cantu, co-founder of the CTE Center at Boston University; Scott Hallenbeck, executive director, USA Football; Chris Borland and Domonique Foxworth, former NFL players; Buddy Teevens, Dartmouth College coach; Jennifer Brown-Lerner, policy manager for the Aspen Institute’s National Commission on Social, Emotional, and Academic Development, and mother of a grade-school boy who plays football; Tom Green, Eleanor Roosevelt High School (Md.) coach; and Dr. Andrew Peterson, representing the American Academy of Pediatrics.
Their insights, many featured below, were supplemented with perspectives gleaned from a post-event online survey distributed to attendees of the event and members of the public, including those who watched on livestream. Survey results and comments shown in this report come from 62 responses by parents, high school and youth coaches, athletic trainers, medical professionals and others. Those perspectives — plus Aspen Institute research — form the basis of this report, which we hope helps parents, football leaders, educators, policymakers and other stakeholders make reasoned and ethical decisions about improving the delivery of the game for youth, our society’s most valuable resource.
Each topic includes a discussion of the points of view shared, and an Aspen Institute analysis.
Our overarching conclusion: Children, the game and communities are likely to benefit if flag football becomes the standard way of playing before high school, with proper tackling technique taught in practice settings in the age group leading into it.
4 Sports & Society Program | The Aspen Institute 10/12/2018 Page 177 Public Health
Tackle football is a collision sport that promotes physical activity and offers psychosocial benefits but can also produce a range of injuries, including lasting damage to the brain. Research on the impact of head injuries has dominated the conversation around public health and football in recent years. While hard-shell plastic helmets are highly effective for preventing catastrophic skull fractures, medical experts recognize they do not prevent concussions nor subconcussive trauma, both of which can occur when an athlete experiences a blow to the head or sudden change in momentum that causes their brain tissue to stretch and warp — in turn resulting in metabolic dysfunction and/or structural damage.
With rest and a gradual return to regular activity, most athletes who suffer a single concussion experience a resolution of symptoms — such as headaches, dizziness and confusion — and no permanent ill effects. However, some suffer post-concussion syndrome, in which symptoms persist for months or years, in rare cases permanently. Multiple concussions are associated with an increased risk of post- concussion syndrome as well as long-term depression and memory problems. Athletes who suffer a second concussion while still recovering from a previous one are at risk for second-impact syndrome, in which the brain swells rapidly and catastrophically, causing severe disability or death.
Repetitive brain trauma also has been linked to CTE, which is characterized by the buildup of a toxic protein called tau in specific areas of the brain and associated with cognitive dysfunction and mood and behavior disorders. In 2017, Boston University researchers reported in the Journal of the American Medical Association that they had found the disease in the brains of 110 of 111 former NFL players, 48 of 53 former college players, and three of 14 former high school players they posthumously examined.9 The study has several important limitations, most notably the lack of a control group, and selection bias
10/12/2018 Sports & Society ProgramPage | The 178 Aspen Institute 5 in the brain collection because families of players with symptoms of CTE are far more likely to donate brains to research than those without signs of the disease. Still, Boston University’s ongoing CTE research suggests a dose-response relationship between “I’m somewhat subconcussive hits and CTE: the more blows taken over time, the higher the risk of developing the disease. incredulous that we even discuss Medical scientists believe children may be particularly vulnerable to brain injury in collision sports like football — in part because the reasonability their brains are physically immature and have still-developing of hitting a 5-year- neural circuitry, and in part because they have relatively large heads and relatively weak neck and shoulder muscles when old in the head compared to adults, increasing the likelihood of a brain-jarring “bobblehead effect” during impacts. A recent Centers for Disease hundreds of times. Control and Prevention report to Congress on the management of It baffles me inside. traumatic brain injury (TBI) in children states that brain injuries: I think you can wait • Affect “children differently than adults.” to play.” • Can disrupt children’s “developmental trajectory” and cause changes in “health, thinking, and behavior that affect learning, — Chris Borland, self-regulation, and social participation, all of which are former San Francisco important in becoming productive adults.” 49ers linebacker • Can negatively affect a child’s “future ability to learn and who retired from the perform in school.” National Football League after one year • Correspond with imaging studies of children that have found due to concerns about “reduced brain size and structural changes in certain areas head injuries of the brain,” supporting the notion that “disruptions in brain systems during childhood could underlie observed behavioral and neurocognitive changes, and academic problems years later. Although the exact effects of a childhood TBI on brain development require more study, emerging physiological and imaging findings of anatomic changes suggest the importance of protecting children from sustaining TBIs.”
In 2013, researchers at Virginia Tech University and Wake Forest University found that 7- and 8-year-old youth football players received an average of 80 hits to the head per season, while boys ages 9 to 12 received 240 hits.10 Some of the impacts were measured at 80g of force or greater, equivalent to a serious car crash.
A 2018 study published in Pediatric Neurology found that college athletes who reported suffering their first concussion before age 10 were twice as likely to have a subsequent concussion than those who reported their first concussion occurred between ages 10 to 18. A 2016 Wake Forest study of football players ages 8 to 13 found that the more blows to the head they sustained over the course of a single season, the more changes were shown in their brain’s white matter11 — bundles of insulated neurons that facilitate communication between different areas of the brain. A 2017
6 The Aspen Institute | Sports & Society Program 10/12/2018 Page 179 Boston University study linked beginning tackle football before “I think if we're going age 12 with increased risk of depression, cognitive impairment, and behavior problems over time.12 to make dramatic
“All of our studies are pointing towards subconcussive impacts changes to the game, causing a change in the brain,” says Elizabeth Davenport, a we need dramatic University of Texas, Southwestern researcher who has studied the brains of youth and high school football players using imaging evidence that what technology. “Everything that we've seen has shown that just a we're doing here has normal football season will cause changes in the brain. And then we also see that if you have a concussion prior to the season, your a real public health brain changes differently. So it points towards a concussion never burden. And I'm not kind of ending.”13 sure that there is a Cantu, co-founder of the CTE Center, says the maximal age for connectivity of brain networks primarily occurs between the ages meaningful public of 10 and 12. That’s the window that significantly helps shape health burden of the what a person will be like as an adult in regards to IQ, emotional makeup, depression, anxiety, panic attacks and impulsivity, among injuries that occur in other areas. “If you injure a brain at that early age, you have later youth football.” life potential consequences,” Cantu says. “Multiple papers we've been a part of have shown if you play tackle football under the age of 12, you have a higher chance later in life to have cognitive — Dr. Andrew Peterson, behavioral and mood problems than if you started at a later age.” University of Iowa football team physician and To reduce the above risk, Cantu advocates that tackle football not executive committee be offered to children until age 14 — flag only until then — and for member of the American similar restrictions on body-checking in youth hockey and heading Academy of Pediatrics the ball in youth soccer. He first proposed as much in 2012 in his Council on Sports book with co-author Mark Hyman, Concussions and Our Kids. A Medicine and Fitness senior advisor to the NFL’s Head, Neck and Spine Committee, Cantu says recent research further supports his point of view.
Former University of Maryland football and NFL player Madieu Williams is currently a law school student and intern in the office of Terri Hill, a physician and Maryland state representative who introduced a bill that would have prohibited children from playing tackle football on public fields until they reach high school. Williams supported Hill’s bill, which did not pass, and says that his own son won’t be allowed to play tackle football until high school. “There hasn’t been a study tracing the impact of concussive impact with brain injuries all the way to adulthood,” Williams says. “That doesn’t mean potential damage is not there. If we can limit exposure of our youth at a young age, given that they have very weak neck muscles and more importantly to protect the brain from any type of injury, it’s very important to do so.”
However, the brain injury risk posed by tackle football is difficult to quantify. A definitive casual link between youth football participation and long-term neurological disease has not been established. Most of the research linking football-induced head trauma to acute and chronic brain changes and damage involves
10/12/2018 The Aspen Institute | SportsPage & Society180 Program 7 former professional and college players; Which scenarios do you think are most likely to athletes whose football careers did unfold by the year 2030, as research, policy, not extend beyond youth and/or high law and other factors evolve? school are not as well-studied. It is unclear exactly how risky youth football participation is, or how many hits to the head over the course of a football career is likely to be too many.
Many individuals who participated in youth and/or high school football appear not to have suffered lasting or clinically significant brain injury. A 2017 study published in JAMA Neurology found that men who played high school football in the 1950s in Wisconsin did not have a higher risk of poor cognitive or emotional health later in life than Source: Aspen Institute survey those who did not play the sport.14 A 2016 Mayo Clinic study found that football players from a Minnesota high school who competed between 1956 and 1970 did not have an increased risk of degenerative brain diseases compared with athletes in other varsity sports.15
Both the short and long-term clinical significance of brain changes observed via imaging studies of youth and high school football players is unclear, though some are concerned. “There's a lot of talk about CTE and these NFL players and having these really detrimental effects on your life,” says Davenport, the UT Southwestern researcher. “But in the youth football players, we see these changes in the brain before we see a change in their behavior and their cognitive ability. So they're still doing really well in school, they're still great kids; we're not seeing a whole lot of changes in their outward personality. But what the MRI and what the MEG see (through images of the brain) is a little bit different, and it is telling this kind of ‘micro-story’ of what is going on in the brain.”16
However, a 2018 op-ed published in the Minneapolis Star-Tribune and co-authored by a neurologist, a neuropathologist, and a lawyer argued that current scientific evidence is not strong enough to support establishing an age of entry for tackle football.17 The article also cautions that restricting participation to tackle football could have an unintended public health cost if it results in fewer children overall playing sports, given that participation offers youth “a way off the couch” and promotes “the adoption of an active lifestyle, thereby mitigating the risks of, among other conditions, obesity, high blood pressure, diabetes, depression, osteoporosis, cardiovascular disease, stroke, drug use, teen pregnancy and, ironically, dementia.”
University of Iowa researchers studied three youth football leagues — one flag, two tackle — consisting of players in the second through seventh grades and found that injuries were more likely to occur in flag football than in tackle. They also found there was no significant difference in the number of severe injuries and concussions between flag and tackle leagues. The study has limitations given that the number of injuries seen in the flag football league was relatively small, and the number of participants in the flag league was much smaller than the number of participants in the tackle leagues. Cantu calls the study “flawed” in several ways, questioning how comparisons could be drawn given its reliance on self- reported data, that only three concussions were found in flag football, and no analysis of subconcussive hits was conducted.
8 The Aspen Institute | Sports & Society Program 10/12/2018 Page 181 Peterson, the paper’s co-author, stands by its findings and believes that children should be able to play tackle football as young as they want. “I don't think we need to legislate or mandate or codify these types of things,” he says. “You know, the rates of injuries are very low here. The things that we're looking at and that Dr. Cantu was talking about are mainly in people that have very, very long playing careers and the vast majority of people that are playing contact collision sports don't have these careers that go on through the NFL lasts decades. I think having a few years of exposure to contact sports as a young person is a fairly safe thing to do, and that we shouldn't make decisions based on what's happening to a handful of people at the NFL level.”
Peterson argues that the health benefits of playing tackle football simply outweigh the risks. His point of view is consistent with that of the American Academy of Pediatrics' Council on Sports Medicine and Fitness, which Peterson sits on. In 2015, the Council issued a policy statement on youth tackle football that acknowledged the sport’s dangers but stopped short of recommending that children not play. Instead, the organization concluded that it should be up to participants to decide whether those risks “are outweighed by the recreational benefits associated with proper tackling” — a softer position than the AAP took in the 1950s, when it recommended that children under age 12 be excluded from body-contact sports, including tackle football.18 Critics howled, noting the organization recommends that body-checking in hockey begin at age 1519 and that no one under age 18 participate in boxing.20 Even some pediatricians objected. In 2017, a survey of AAP members found that 77 percent would not allow their son to play tackle football and that 81 percent endorse limiting or eliminating tackling from football practices.21
ASPEN INSTITUTE ANALYSIS Peterson’s point is not to be overlooked, and he is not alone in recognizing the larger picture. Among youth, only 36 percent of males and 17 percent of females today get the recommended level of one hour of daily physical activity, according to Centers for Disease Control and Prevention; stakeholders recognize the need to get more of them moving, given the documented mental and physical benefits that flow to those whose bodies are in motion. Tackle football is one option for children, especially for heavier kids, a factor that deserves consideration given the health-care costs tied to obesity-related
10/12/2018 Sports & Society ProgramPage | The 182 Aspen Institute 9 illnesses. If just half of all youth become physically active at the recommended level, and stay active into adulthood, the nation will save $20 billion in direct medical costs and $32 billion in lost economic productivity, according to projections by the Global Obesity Prevention Center at Johns Hopkins University that were commissioned by the Aspen Institute.
At the same time, it’s hard to quantify the value that tackle football brings to that opportunity. Only 2.9 percent of children between ages 6 to 12 played the game on a regular or “core participant” basis in 2017, according to Sports and Fitness Industry Association (SFIA) data. Further, it’s unclear how early participation in tackle football impacts a person’s desire or ability to be active for life. If a child suffers a knee or spinal cord injury that limits their mobility into adulthood, or a brain injury that affects emotional or cognitive function, what are the downstream costs on the individual and public health at large, including taxpayer burden? More research is needed to tease out answers.
To their credit, football leaders aren’t waiting for all answers to come in to begin reforming youth tackle. Pop Warner has issued limits on tackling and contact in practices, and eliminated kickoffs. USA Football, the NFL-supported entity that helps guide the development of the sport nationally, has created coaching education modules and in 2017 introduced a “Rookie Tackle” pilot program that has a smaller field and fewer players. However, other sports have moved more aggressively to reduce and eliminate blows to the head. The U.S. Soccer Federation has banned heading the ball for children under age 10 and limited headers in practice for children ages 11 to 13. USA Hockey has delayed the introduction of body- checking in games until age 13 — while teaching such skills in practice in the age group leading into it. Hockey Canada followed suit in 2013; injuries subsequently fell by half and concussions were reduced by two-thirds.22
The emerging evidence suggests that football can make a more meaningful contribution to public health by holding off on offering tackle until at least adolescence. If the hockey model were to be followed, football players would learn proper tackling techniques in controlled practice settings in the year or two leading up to the age at which tackling is introduced in games, allowing for a safer introduction to such activity.
In public health, another consideration is the precautionary principle, which holds that in the case of serious or irreversible threats, acknowledged scientific uncertainty should not be used as a reason to postpone preventive measures. That principle is now being engaged by some pediatricians, who have started refusing to sign pre-participation physicals for youth tackle football. The burden of proof in demonstrating safety or harm has shifted away from critics to those providing sport programming, who bear a special obligation given that in their hands are the lives of children.
10 The Aspen Institute | Sports & Society Program 10/12/2018 Page 183 Youth Participation
Jennifer Brown Lerner is torn. She has fond memories of growing up in Georgia, immersed in the culture of football — from the rooting interests to the tossing of balls in the front yard with her brothers. So on the one hand, she wants her two young sons to be able to play the game. But on the other, she doesn’t want them to be seriously injured. “I remember as a child, and still do, my family has a pickup game over the holidays when we're together,” says Lerner, policy manager for the Aspen Institute’s National Commission on Social, Emotional, and Academic Development. “I don't want my kids to be like, ‘What’s a first down?’ That's not okay. That's almost un-American. “But I struggle with what the [medical] research is telling us … as a parent you have this emotional response … and that makes you think long and hard about whether or not you want your own child to participate in this.”
Lerner’s reluctance to allow her children to play tackle football isn’t unique. In 2013, President Barack Obama told The New Republic, “If I had a son, I'd have to think long and hard before I let him play football.”23 Citing health concerns, active and retired National Football League players have stated publicly that they will not allow their own children to play tackle until junior high or high school age.24 The New York Times even reports that parents’ concerns over tackle’s safety are “surfacing in legal battles between divorced couples, leading to an increase in fights over whether to amend custody orders to prevent their children from playing the game.”25
Flag football offers a less-worrying alternative — a way to keep safety-conscious parents and families from abandoning the sport altogether, and to slow or reverse the ongoing decline in overall youth football participation. In Florida, for example, a youth flag league founded by former University of Maryland quarterback John Kaleo has served more than 7,000 kindergarten Youth Tackle Football Coaches With Training through middle school-aged children since Percentage of coaches who say they are trained its 2014 inception and is now sponsored in key competencies has fallen by the national sports apparel company Under Armor. Participants in the 7-on-7 2012 2017 league use tackle football plays, concepts and terminology. “Today's parents are CPR/Basic First Aid 55.9% 51.5% very concerned about the safety and the head injuries that are occurring in physical Concussion Management 43.6% 38.8% sports like football,” Kaleo told the Tampa Bay Times in 2017.26 "There's a large group General Safety/Injury Prevention 53.1% 43.4% of kids that still want to play football, Physical Conditioning 52.4% 44.9% but they're hesitant to put a helmet and shoulder pads on.” Sports Skills/Tactics 46.7% 43.3% In Mobile, Alabama, former NFL general Effective Motivational Techniques 32.6% 34.6% manager Phil Savage helped run an NFL flag football league. The goal, he says, is to give Source: Sports and Fitness Industry Association data from national surveys taken by families an alternative pathway for children to Sports Marketing Surveys
10/12/2018 The Aspen Institute | SportsPage & Society 184 Program 11 “I’m not talking about enter into football and possibly play tackle as a teenager. “I played tackle at 6 years and up,” says Savage, who recently departed as abolishing football. executive director of the Senior Bowl, a week-long event for the I want more people NFL to scout college prospects. “I think it’s a different generation to play football. I just now. There’s a lot more information out there regarding safety and concussion concerns. My personal feeling is I think you should want youngsters at wait (for tackle) until you’re a teenager. I would have hesitancy with highest risk not to be youth tackle football because of the safety and the coaching that’s getting their head hit out there, though I’m sure there’s some amazing coaches.” 200 times over the Despite the push by USA Football in recent years, most youth course of an average coaches remain untrained in key competencies. Only 38.8 percent of adults who have coached football teams of children ages 14 season, because you or under in the past five years say they have received education couldn't do that to in concussion management, and only 43.3 percent say they have been trained in sport skills and tactics; those numbers are your child and get actually down from 2012 (see chart on page 11). The inability away with it — and to move those numbers reflects the state of youth coaching, I certainly couldn't which is dominated by a revolving door of volunteers and, in football especially, locally-run independent leagues with minimal have done it to mine oversight. — and yet they can do In that vacuum, coaches still sometimes promote dangerous prac- it to themselves on tices, such as the Oklahoma drill, in which children slam into each athletic fields.” other, one on one, to promote toughness. An article on the USA Football website in 2018 said that the drill “shouldn’t be used until 27 — Dr. Robert Cantu, players have the physical and cognitive ability to execute it safely.” on why he supports flag Physical aggression, domination, and violence are at the core of football instead of tackle tackle football’s appeal to both spectators and participants. A before high school Tampa, Fla.-based youth tackle league that plays fall and spring seasons promises to let its 3,000 members “play the game the way it was meant to be played.”28 While the league also offers flag football for children ages 4 to 6, its president, Scott Levinson, told the Tampa Bay Times in 2017 that flag is not a sufficient substitute for tackle: “If you're playing a game of H-O-R-S-E or 21 in basketball, you are nowhere near as intense as you are if you were playing a game of 5-on-5. I believe it requires much more intense teamwork. I believe it requires much more trust."
If purposeful hitting and collisions are removed from youth football, it’s possible that children and parents who want those elements may pursue other sports — or no sports at all. Children looking to emulate popular high school, college, and professional tackle football players may be particularly discouraged. Dr. Uzma Samadani, a Minneapolis neurosurgeon who has authored articles opposing youth tackle football bans, cautions that “children with no predilection for speed sports requiring stamina or endurance” — such as the “heavier or asthmatic child who can’t run well enough to play flag”29— may be left with few sports options without tackle.
Peterson, the University of Iowa football team doctor, adds: “There are only so many opportunities for people that want to do physical things. Like, there are certain people that really like contact — like
12 The Aspen Institute | Sports & Society Program 10/12/2018 Page 185 pushing someone else around, doing something that's a little bit more violent. And football is one of the reasonable outlets for that. There are other sports that are a lot like that … some of the combat sports are like that, wrestling is like that, hockey is like that “Short of combat to some degree at the higher levels. But I do think we worry about sports, boxing and alienating these kids. I think football is an outlet for that type of MMA and karate or physicality for kids that want to push other people around.” whatever, there is no other mainstream ASPEN INSTITUTE ANALYSIS sport where you can Replacing youth tackle football with flag likely would result in go as a little boy up reduced participation by children and families for whom hitting, blocking, and tackling are the point and purpose of the sport — the against another little only reason to choose it over, say, baseball or swimming. However, boy and pretend like it is unclear how many of the roughly one million youth who you're a man and try currently play the game would opt out. We suspect most would adapt to flag and the game would prosper, just as hockey did after to beat them. When it introduced its body-checking ban. Since 2012, the number of you're 5 or 6 years old children playing hockey on a regular basis is up 56 percent (to 512,000 children ages 6 to 12), more than any other team sport and you see movies tracked by the Aspen Institute through the SFIA annual survey data. that are about men
More importantly, prioritizing flag before high school holds the being strong and prospect of inviting into the game many potential participants tough, and you see who otherwise are inclined to steer clear of football due to injury ads about the military, concerns. It could remove the psychosocial stigma of boys being, as former NFL cornerback Domonique Foxworth puts it, “just a about men being little bit softer” than their tackle-playing peers, while also making strong and tough, the the game more attractive to girls. Last year, females across all idea that you can grab age groups accounted for only 5 percent of tackle football’s core player population — and nearly 18 percent of flag football’s core on to something like player population.30 that and you can go to USA Football currently takes the position that flag and tackle are school in your football both good, at all ages. It has no plans to recommend a minimum jersey and that age to transition from the former to the latter, and in many communities that happens around age 7 or 8. However, that stance separates you from all could change, USA Football executive director Scott Hallenbeck the other kids, all the told attendees at our January event. “As [medical] information [on other boys, who are football’s risks] continues to come out, I know USA Football and our board and, I think, really every stakeholder I talk to is all about, just a little bit softer ‘We're going to have to follow the science, period,’” he said. “So than you — it’s all as this continues to come out, we have to pay attention to that, we part of your thought have to continue to address repetitive hits. That is unequivocal.” process.” Lerner already has made her decision. Her 8-year-old son has been playing flag the last two years. “Flag has been a great way — Domonique Foxworth, to not only expose my son to football, but also to gain a lot of the writer at The Undefeated skills and experiences that we really want as parents — and that [the] commission I work for is really pressing through participation and former NFL cornerback, in sports,” she says. “I'm thrilled, I have an option K-8 for my kid on the appeal of tackle to play football. I’m going to think long and hard about what football to young children happens after that.”
10/12/2018 The Aspen Institute | SportsPage & Society 186 Program 13 Friday Night Lights
Similar to its youth counterpart, high school football has suffered a participation decline, falling from 1.14 million players in 2008 to 1.07 million in 2017.31 According to the National Association of State High School Federations, 41 states saw a drop in players between 2011 and 2016, and a disbanding of programs in Maryland, New Jersey, and California.32 In 2017, 20 schools discontinued 11-player football, and additional public reports of cancellations surfaced prior to the 2018 season. In Vermont, where Dartmouth is located and high school football has faded, tackle football at all middle schools has been eliminated, with a mandated shift to padded flag.33 In padded flag, players continue to wear helmets and pads, and there is contact at the line of scrimmage. However, every player also wears flags around their waist, and any ball carrier may be tackled only by pulling off one of the flags.
Could a wider pipeline of players coming up through flag deliver more bodies and enthusiasm for tackle football at the high school level? Once hooked on flag, with teaching of tackling techniques in practice, how many of them would want to transition into tackle come ninth grade? How much sway could a parent have in preventing as much?
These are questions worth asking for anyone who values the institution of high school football, whose role in many communities runs deep. Friday Night Lights are seen by many as a useful and even essential venue for students and adults to come together for a shared purpose, especially in small towns. The viability of fielding teams is threatened when participation drops, as football needs roster At what age, if at all, do you think tackle football sizes that well exceed the number should be introduced to youth? of players on the field, due to its relatively high injury rate (tops among high school sports34) that sidelines players in-season.
Tom Green, Eleanor Roosevelt High School coach and athletic director in Greenbelt, Maryland, says that delaying first exposure to collisions until high school could place participants at greater injury risk, if they are unaccustomed to contact and untutored in the skills of blocking and tackling. Other coaches share this concern. “Flag is a good alternative for youth prior to middle school — it is a good vehicle for teaching fundamental skills and developing a love for the game,” says Mike Mach, an assistant football coach at Detroit Source: Aspen Institute survey
14 The Aspen Institute | Sports & Society Program 10/12/2018 Page 187 Catholic Central High School in Novi, Michigan. “I believe that “I think a lot of the to forbid contact football until high school is excessive, and it eliminates far too many opportunities to teach safe participation at youngsters need to a young age.” learn how to tackle. Some also wonder if delaying tackling until high school will . . . [The] basis is still diminish the quality of players at the high school level, and blocking and tackling. beyond. Carter Caplan, a Drexel University sports management student who aspires to become a college athletic director, says So I think [age] 10 is that “practice makes perfect. You need to put in years of training too young. But one in order to get recruited, and I believe the skill level in college or two years before football would go down if the athletes are not allowed to start learning how to play the game correctly and developing their skills high school to teach from a young age.” them how to tackle Skills matter — though so do size, speed and strength, often the and how to block separating factors between a good high school player and one with equipment, I who gets an offer from a Division I college program. think that's important. Dartmouth College coach Buddy Teevens thinks high school You may have more football will be just fine if tackling is introduced in games in injuries if the kids ninth grade, and in limited doses. His confidence is rooted in his experience at Dartmouth, where six years ago he and his staff don't start playing eliminated all tackling outside of games. “It was a combination until high school.” of things,” he says. “Concussive head injury, studying my players’ injuries, I just thought there had to be a better way. It was not the most well-received thing with my coaching staff. We thought, — Tom Green, ‘We're done. We'll be fired.’ But I thought it was the best move for Eleanor Roosevelt High my players.” School (Greenbelt, Maryland) coach and Since then, Dartmouth has enjoyed a winning record in five out athletic director of seven seasons and captured an Ivy League championship. “Concussive head injuries have dropped appreciably,” Teevens says. “Peripheral injuries have dropped appreciably. My guys are playing healthfully. We have less subconcussive [hits to the head] than anybody in the country at the [NCAA] Division I level.”
Teevens’ players still practice tackling — just not against each other. They perform drills designed to minimize injury and avoid head contact, and sometimes practice by tackling a specially-designed robot. He says Dartmouth now is one of the best tackling teams in the country and misses only five tackles per game. “Why is that? The skillset of tackling can be taught on inanimate objects, and that's my big push,” Teevens says. “I think there's way too much contact at any level. I think coaches are the ones who drive it.
“[When] I spoke with [the] American Football Coaches Association, I said that our collective body can fix this right now. We design practices. We approve drills. We say yes or no, if we push contact and aggressiveness, our players are going to reflect it and they're going to get hurt. It's a real simple equation: the more you hit, the more you will get hurt. [So] minimize contact.”
10/12/2018 The Aspen Institute | SportsPage & Society 188 Program 15 ASPEN INSTITUTE ANALYSIS “Yeah, I'm okay New England Patriots quarterback Tom Brady did not play tackle waiting (on tackling) football until high school. Nor did Pro Football Hall of Fame until high school. You members Jerry Rice, Jim Brown, Walter Payton, Anthony Munoz, know, I don't have Warren Sapp, Mike Haynes, Michael Strahan, and Lawrence Taylor — several of whom were known for their tackling ability. There’s (any) problems. … no evidence to suggest youth tackle participation is a necessary Can they learn the precondition for high school, college and professional success, skill set? I think that nor any showing that exposure to tackle football prior to high school reduces the risk of injury. they can. I'm also a realist, and I'm not As such, we project that making flag the standard way of playing football until high school ultimately will benefit an institution many sure people in this stakeholders care to preserve and enhance. Safety-conscious country will eliminate parents and children will be more likely to participate in youth flag, expanding the pool of potential high school players. High tackle football. My school players will enter tackle football with less prior exposure to approach is, how collisions and head injuries that could sideline them permanently, do we mitigate and given that each concussion makes an athlete more susceptible to additional concussions. limit the amount of tackle or contact at We find it unlikely the quality of high school play will be diminished overall, or the quality of college recruits, if coaches the different age teach the game effectively. Green says the skills of quarterbacks groups?” and wide receivers would not change, adding, “I think it may affect the linemen, the big kids up front, the blocking, [a] lot of those kids get an opportunity to play now with tackle football.” But — Buddy Teevens, Green also says high school coaches could adjust and prepare head coach, players for college if flag became the standard for kids up to 14. Dartmouth College Teevens believes key features of Dartmouth’s model can be adopted at the high school level, both to reduce exposure to head trauma and better teach athletes how to tackle. “Can you learn a [tackling] skillset [starting in high school]? Yes, I think that you can … and it's on coaches,” he says. It’s all on the coaches, who will have to innovate and lead in new ways.
16 The Aspen Institute | Sports & Society Program 10/12/2018 Page 189 Football Industry
More money flows through football than any other sport in the U.S. Public universities that are in college football’s highest division make more than $8 billion for their athletic departments35, with football supplying the vast majority of that revenue, helping fund top-tier football programs and teams in other NCAA sports. The NFL is a $14 billion industry whose commissioner, Roger Goodell, has set a goal of pushing that number to $25 billion by 2027.36 Media companies like ESPN recognize that kids who play a game are three times as likely to become “avid fans” — their core customers — as those who don’t play, and that connection is enhanced the earlier that a child gets exposed.37 The bottom lines of helmet manufacturers are heavily dependent on enthusiasm for tackle football at the youth levels.
All of these industry players, and more, have a vested interest in the future of the youth game. Not all of their interests align perfectly. But all play a role in shaping the model that emerges.
Much of the football industry's energy to date has gone into holding on to its base of true believers in tackle football for youth, encouraging parents who are inclined to sign their child up that the risks are no greater — or less great — than other childhood activities such as bicycling or skateboarding.
A palpable fear runs through Rank, on a scale of 1 to 10, the groups that bear the most some of the messaging responsibility of leadership in evolving the game of suggesting this is an existential youth football (through age 14)? issue for the game at all levels, a notion that some observers of the game subscribe to.
Predicts Dr. Thayne Munce, associate director of the Sanford Sports Science Institute, “If you convince the public — and mothers in particular — that tackle football is too dangerous for kids to play, narrow the pipeline of players to [high school] football, and shrink the fan base, tackle football will collapse upon itself. All the way up to the NFL.”
Sharing a similar point of view is documentary filmmaker Sean Pamphilon, director of The United States of Football.
Source: Aspen Institute survey “Banning tackle football for kids
10/12/2018 The Aspen Institute | SportsPage & Society 190 Program 17 until high school becomes the warning label on the cigarettes,” he says. “It will impact the way we see the game once we truly are honest about the way it impacts human beings of any age.” “I think this discussion Analogies have been made to boxing, which in the first half of is much bigger than the 20th century was among the nation’s most popular spectator asking if flag football sports. Boxing began to fade for a mix of reasons, among them greater awareness of the brain damage suffered by, with slurred should be played speech of, well-known professional fighters. Today, boxing is a before high school. niche sport, watched by relatively few, with its participants drawn almost exclusively from lower socio-economic communities. The entire future Compared to other team sports, football already pulls more often of football in the from lower-income homes, and analysts have predicted that trend continuing as families with means find sports with less injury risk. [United States] will Others find the boxing comparison to be overstated. The NFL and be affected by this college football providers have an array of assets at their disposal direction.” to ensure the game’s continuation as a mass spectator sport, among them infrastructure (fields and stadiums) that schools, universities and governments have invested in, long-term media — Thayne Munce, contracts that ensure publicity and money, and scores of billionaire Associate Director, franchise owners and university trustees with the influence to look Sanford Sports out for football interests. Science Institute Some segments of the industry are more vulnerable to disruption than others, if flag becomes the youth standard. The most obvious: Manufacturers of protective equipment for tackle football. A Riddell youth helmet with “patented side protection” alone costs nearly $400. Among the opportunities to adjust their business model in a flag-first environment: Sell more lightweight or soft-shell helmets that protect against incidental contact38, or shoulder pads that permit flag or touch players to “dress up” and cosmetically emulate the contact version of the sport. HIP Football, a two-hand-touch youth variation of the game founded by former University of Alabama and Baltimore Ravens player Tim Johnson, offers that opportunity.39 Such equipment could be useful in introducing tackling techniques in controlled practice settings as children approach high school.
Similarly, youth football organizations currently associated with tackle football may have to reinvent themselves. Pop Warner is the oldest such organization in the country, founded in 1929 with teams for adolescents. Over the years, it has added divisions for kids of increasingly younger ages; tackle now starts at age 7 (Mitey Mites). At an Aspen Institute roundtable in 2012, Pop Warner executive director Jon Butler doubted he could promote flag aggressively without families fleeing to independent leagues that offer tackle. He expressed a similar sentiment in 2017 when asked by the New York Times about introducing a modified version of tackle football for children that would reduce the size of the field, the number of players participating, and the amount of physical contact that takes place. “We’d get a rebellion if we tried this because so many people don’t want to be told what to do,” he said.40
18 The Aspen Institute | Sports & Society Program 10/12/2018 Page 191 ASPEN INSTITUTE ANALYSIS Whether the football industry wins or loses from any shift to flag as “Living in reality, I the youth standard is largely a function of how readily it embraces disruption. Just as some media, transportation, telecom, and other don’t think tackle companies thrived when technology challenged their prevailing football is going business model and forced them to innovate — and other compa- nies merely tweaked their models and floundered — it’s reasonable away, but I think the to conclude that so, too, will each respective football entity. idea of (creating) a A key question is how many children the industry believes it framework and more can engage. To date, leaders have been reluctant to forcefully challenge its current base with a new model, concerned that it entry points, gives might lose families of the 2.9 percent of kids who play tackle, parents the choices especially in traditional strongholds like Texas and Louisiana. Again, that’s a pretty small number, and as more studies emerge they need. … Why do offering new insights on brain trauma, it’s hard to imagine it you have to stop (flag) growing much. Flag is a lower-cost, more-accessible form of the game for many children. If that becomes the standard, and it’s at 14? Nevada and promoted more vigorously in schools and communities by the NFL Florida actually have and college football, it’s not hard to imagine football closing the gap in the regular participation levels of basketball (14.1 percent), girls flag in varsity baseball (13.1 percent) and soccer (7.7 percent) for kids ages 6 to sports. We want 12. And with every new participant comes new data and marketing relationships that can be developed. to talk to the state
Legal risks will drive some of that disruption. They already have. associations and really In 2016, a California football player, the late Donnovan Hill, won a see an opportunity to seven-figure settlement from Pop Warner; he was paralyzed and his brain damaged at age 13 after a headfirst tackle maneuver stay in a sport for a taught by his untrained coaches. The settlement exposed the long period of time.” vulnerability of volunteer coaches, who were sued, as well as the weakness of indemnification clauses in preseason documents presented by teams and signed by parents presumably on behalf — Scott Hallenbeck, of their children. Weeks later, Pop Warner settled another lawsuit, USA Football this one a $5 million wrongful death claim brought by the mother executive director of another former player who died and was diagnosed with CTE for an undisclosed amount.41 Currently, Pop Warner is facing a suit brought by the mothers of two former players who died and were subsequently found to have CTE; that one’s a class action, representing all players since 1997.42
Standardizing youth flag should help reduce both insurance and equipment costs, which in turn may grow access to what can be an expensive game. Football also will be better positioned to capitalize on the growth of female sports participation, rather than making do with a relative handful of girls’ tackle players and leagues while losing athletes to other sports. Finally, standardized youth flag could lead to more ongoing high school, college and adult flag participation — growing and benefitting the football industry as a whole, and transforming the sport into an activity for life, like tennis, which welcomes participants from age 5 to 55 and can be played in a variety of settings, from pickup games to family outings.
10/12/2018 The Aspen Institute | SportsPage & Society 192 Program 19 Civic Life
In January 2018, days after our Future of Football conversation, USA Football held its annual conference in Orlando, Florida. We attended that event, where former NFL players, coaches, and Sen. Marco Rubio gave a series of speeches to roughly 1,000 coaches and administrators. The general tone was both laudatory and defiant — celebrating the sport’s place in American society while defending it against the perception it may be too dangerous for kids. Among the speakers was Pro Football Hall of Fame President David Baker, who stated that America might not survive if it loses football. He’s not alone with the doomsday predictions. University of North Carolina coach Larry Fedora recently told reporters, “I fear that the game will get pushed so far to one extreme you won’t recognize the game 10 years from now. That’s what I worry about, and I do believe if it gets to that point our country goes down, too.”43 “If we lose football, we These expressions reflect a cultural notion about the role of football lose a lot in America. I in our society. Around the start of the 20th century, the game was don’t know if America among the sports promoted by leaders, including President Teddy Roosevelt, as a tool of nation-building. It was seen as a venue can survive.” to channel the unruly energies of adolescent males and build generations of soldiers and factory workers for our expanding, — David Baker, then-largely industrial economy. The game only grew in popularity president, after a couple of World Wars, and all the symbiotic metaphors. Pro Football Hall of Fame President Dwight Eisenhower, who had played at West Point, wrote that “football, almost more than any other sport, tends to instill into men the feeling that victory comes through hard — almost slavish — work, team play, self-confidence, and an enthusiasm that amounts to dedication.”44
These continue to be bedrock values in our culture. The questions to ask are: If flag becomes the standard way of playing the game until high school, can these values be taught as readily? Do we end up with generations of children who lack resilience, and the ability to work together, if bodies and heads collide less at the youth level? Do youth grow into adulthood less employable, or less interested in military service? What do we lose, if anything?
Nothing, some suggest. “In the [U.S.], we had robust civic life and leadership development before there was anything like football, and we can have that again,” says Jeff Prudhomme, vice president of the Interactivity Foundation, a nonprofit that explores public policy solutions through small group discussions. “There can be other sports around which communities can come together without risking the cognitive faculties of their young people. Leadership development can be engaged through many different sports, and through non-sport activities including the arts, in ways that doesn't endanger the lives of those we seek to help develop.”
20 The Aspen Institute | Sports & Society Program 10/12/2018 Page 193 Former NFL player Donté Stallworth is skeptical of the point of view that all kids can just take up other activities. Growing up in what he called a “rough” neighborhood engulfed by gangs and drugs, he wrote in the New York Times,45 football taught him “teamwork, perseverance [and] Football Participation accountability” that has served him well. Percentage of kids 6 to 12 who participated on a regular basis “For many communities, including my own, sports provided one of the only 2012 2017 # Kids in 2017 outlets to avoid even greater dangers. Flag Football 2.8% 3.3% 988,260 And sports taught me life lessons, at an impressionable age, that I may not have Tackle Football 3.6% 2.9% 871,465 learned otherwise.”
Source: Sports and Fitness Industry Association data from national surveys taken by Sports Paul Watkins, a Pop Warner regional Marketing Surveys. director, says football works hard to Note: Regular participation usually includes a level of organized play. remain accessible to kids who lack the means to participate. He told the San Diego Union-Tribune46 in 2017 that his organization offers scholarships to players, requiring that they maintain good grades, and provides instruction about teamwork and community. “It’s a team sport that crosses all racial and socioeconomic barriers,” Watkins said. “Once you get on the football field, it’s all for the team. Kids learn a lot about each other. What we’re basically doing is trying to prepare these young men to be successful as men.”
Foxworth, the former NFL player and NFLPA president, believes that loss may be felt most profoundly in African-American communities, where football is sometimes one of the only available youth sports and points of civic pride. “The frightening thing for me is [if] you remove football, [then] what do you replace it with for opportunities for those communities?” he says.
Borland, who retired after one NFL season due to concerns about brain injuries, says that flag football, and other sports, must be introduced, if we’re looking to develop the traits tackle football most associates itself with. He has worked with University of Wisconsin neuroscientists who are studying how to develop resilience in the brains and minds of young people. “Compromising the organ that would constitute that development is silly,” he says. “To me, I think a broader definition of toughness is restraint, not the capacity to do harm, but the capacity to do harm and then not. Martial arts are a great way to do that.”
ASPEN INSTITUTE ANALYSIS We appreciate the hazards of merely eliminating tackle football in communities of need, without a replacement strategy that includes the addition of new sport offerings. It’s impossible to teach the values and character traits that we hope sports imparts if a child is stuck on a couch with no options. Physical inactivity and obesity are greater threats to their health and vitality, and to our society, than the risk of getting injured playing football or other sports. We also recognize that football can offer psychosocial benefits to youth that are valuable.
At the same time, there’s a developmentally appropriate time for everything. Life lessons are best taught when youth have the mental maturity and perspective to process them; before they reach adolescence and perhaps high school, it’s more about creating experiences where kids can have fun with their friends and develop physical literacy, or all-around athleticism that lays the groundwork for them to be active for life. Pre-teens are likely to learn more about sportsmanship, leadership and integrity from watching a coach who honors the game, its rules and his players, than one who offers long postgame lectures.
Historically, most of the programs designed to develop character through football were aimed at adolescents. Tackle football for second- and third-graders wasn’t part of the original plan, in most
10/12/2018 The Aspen Institute | SportsPage & Society 194 Program 21 “If we can rally schools or Pop Warner. The game has just evolved that way, increasingly over the past generation, driven by sufficient around football, marketplace demand from parents who aim to position their child for success in the sport. we can certainly We suspect that flag football could prepare children for the rally around any world ahead no less readily than tackle football, and other sports, especially if delivered by coaches trained to work with youth. In other sport.” doing so, we suspect the values that we most hope get transmitted via football — from grit to self-sacrifice — will be upheld and elevated. Flag football for kids may even open new vistas, such as — Steven Horwitz, enhanced respect among boys for girls that comes with mixed- founder, gender play. TeamSafe Sports
22 The Aspen Institute | Sports & Society Program 10/12/2018 Page 195 Conclusion
In 1907, the Journal of the American Medical Association condemned tackle football participation for anyone under age 18, calling it “no sport for boys to play.”47 Until the 1950s and ‘60s, tackle football before high school was uncommon. So while the notion of holding off on it until then may seem radical, it’s nothing new. This debate merely has been pushed to the forefront because it’s clear how much more is at stake now, starting with brains of children, which need to function effectively and efficiently to thrive in the new, information-based economy.
None of the bills that state legislators have put forth proposing to prohibit tackle football before adolescence have passed. We expect any attempt to impose a minimum age for tackle football participation via government intervention will continue to face an uphill battle. Laws designed to protect children from potential harms are not unheard of — as with the federal Children’s Online Privacy Protection Rule limiting the collection of information from kids under age 13 — but getting them passed is challenging and in this case, the idea of government limiting what parents do with their children could stoke public discontent and partisan politicization. (President Donald Trump has not weighed in on youth football, only the NFL, saying the league is “ruining the game” through its efforts to restrict dangerous tackling. “Because you know, today if you hit too hard — 15 yards! Throw him out of the game,” he tweeted in 2017).
Many youth tackle programs take safety seriously, minimizing head contact and dangerous activities in practice. Regardless, the game of football is changing and will continue to do so, driven by medical and legal considerations. We see it as a positive development that flag last year passed tackle in popularity among 6- to 12-year-olds, and project more benefits will flow to children, society and most stakeholders if flag becomes the standard way of playing the game until high school.
Getting there will require leadership. Specifically, we recommend:
• USA Football, Pop Warner, and all other youth football organizations shift to a standard of flag football before age 14.
• Those same organizations begin to teach fundamental blocking, tackling, and hitting skills in practice at age 12 — the better to prepare interested athletes for high school football — and do so in a controlled, safe-as-possible manner that does not involve player-to-player and helmet-to-helmet hitting and contact, akin to what the Dartmouth football team does in its practices.
• High school and college football programs also minimize non-game tackling and player collisions by adopting Dartmouth-style instruction and practice standards.
• The football industry and other relevant stakeholders — including high schools and colleges — expand their flag football offerings so that individuals can continue to participate in the sport without having to transition to tackle.
To be effective, these recommendations need full, interlocking support from both the football and medical communities. In the 1990s and 2000s, the NFL spent more than $100 million promoting youth
10/12/2018 The Aspen Institute | SportsPage & Society 196 Program 23 tackle football and in 2014 invested $45 million in programs created by USA Football. Shifting more of the investments to youth flag and the training of coaches as kids approach high school likely would reap demonstrable results.
Drew Brees has certainly seen the marketplace respond. Among the growing number of NFL veterans who has questioned the point and purpose of youth tackle, the New Orleans Saints quarterback in 2017 started a mixed gender flag football league in Louisiana that serves kids from kindergarten through 10th grade. Brees’ Football ‘N’ America already has placed leagues in California, Louisiana, Illinois, Indiana and Ohio. “I would not let my kids play tackle football right now,” he said.48 “I don't think that's necessary, and I don't think it's as fun at this level, and I just think there's too much risk associated with putting pads on right now at this age.”
Next up for his flag league? Texas, where he grew up playing flag until the start of high school.
"I think that this has the opportunity to really save the game of football, honestly,” he said.49
And perhaps, more importantly, enhance the lives of millions of children.
24 The Aspen Institute | Sports & Society Program 10/12/2018 Page 197 Endnotes
1. National Federation of State High School Associations, 2017-18 participation data. This figure counts for boys and girls of all levels of tackle football, from 11-player down to 6-player. 2. 2017 Sports and Fitness Industry Association Tackle Football Single Sport Participation Report. 3. UMass Lowell Center for Public Opinion Research Citizen Attitudes about Sports, Concussions and CTE, May 31-June 6, 2016. 4. "California Would Bar Organized Tackle Football Before High School Under New Bill," Los Angeles Times, Feb. 18, 2018. 5. "Bills in Illinois, New York Propose Age Restriction For Tackle Football Among Youths," Washington Post, Jan. 25, 2018.
6. “Maryland Bill Would Bar Tackle Football For Kids on Public Fields Until High School,” Baltimore Sun, Feb. 6, 2018. 7. "Can a Group of Former NFL Players Convince Parents to Only Let Their Kids Play Flag Football?" USA Today, Jan. 18, 2018. 8. CTE Awareness Foundation. 9. Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football, JAMA Network, July 25, 2017. 10. “Hits to the Head Don't Differ With Age, Research Indicates,” New York Times, Sept. 24, 2013. 11. Subconcussive Head Impact Exposure and White Matter Tract Changes over a Single Season of Youth Football, RSNA Radiology. 12. “Playing Tackle Football Before 12 Is Tied to Brain Problems Later,” New York Times, Sept. 19, 2017. 13. Age at First Concussion Influences the Number of Subsequent Concussions, National Center for Biotechnology Information. 14. Association of Playing High School Football with Cognition and Mental Health Later in Life, JAMA Network. 15. High School Football Players, 1956-1970, Did Not Have Increase of Neurodegenerative Diseases, Mayo Clinic. 16. “A Single Season of Football Can Change a Kid's Brain, New Research Shows,” KERA News, Jan. 17, 2018. 17. “"Does CTE Call For An End to Youth Tackle Football?” Minneapolis Star-Tribune, Feb. 10, 2018. 18. Tolerable Risks: Physicians and Youth Tackle Football, The New England Journal of Medicine, Feb. 10, 2016. 19. American Academy of Pediatrics Guidelines on Reducing Serious Injuries in Youth Hockey, May 26, 2014. 20. American Academy of Pediatrics Policy Statement – Boxing Participation by Children and Adolescents, August 2011. 21. Attitudes and Counseling Practices of Pediatricians Regarding Youth Sports Participation and Concussion Risks, National Center for Biotechnology Information, May 2017. 22. “Canadian Youth Hockey Injuries Cut in Half After National Policy Change,” Reuters, March 21, 2017. 23. “Barack Obama Is Not Pleased: The President on His Enemies, the Media, and the Future of Football,” New Republic, Jan. 27, 2013.
24. “NFL Players Will Let Kids Play Football — If They Start Older,” ESPN.com, April 2, 2016. 25. “Football’s Brain Injury Crisis Lands in Family Court,” New York Times, March 5, 2018. 26. “Future of Football: Flag Vs. Tackle the Concussion Battleground For Children,” Tampa Bay Times, June 2, 2017. 27. “Why the Oklahoma Drill Can Wait For Youth Football,” USA Football website, March 28, 2018.
10/12/2018 The Aspen Institute | SportsPage & Society 198 Program 25 28. “Future of Football: Flag Vs. Tackle the Concussion Battleground For Children,” Tampa Bay Times, June 2, 2017. 29. Dr. Uzma Samadani, Twitter post, Feb. 12, 2018. 30. 2017 data from Sports and Fitness Industry Association. Core participation means playing football on a regular basis as defined by SFIA and usually includes a level of organized play. 31. National Federation of State High School Associations, 2017-18 participation data. This figure counts for boys and girls of all levels of tackle football, from 11-player down to 6-player. 32. “Football's Decline Has Some High Schools Disbanding Teams,” Associated Press, Oct. 6, 2017. 33. “BAMS Switches to Padded Flag Football,” Brattleboro Reformer, July 13, 2017. 34. National High School Sports-Related Injury Surveillance Study, Colorado School of Public Health. 35. Data from USA Today Sports athletic department revenue database for fiscal year 2017. This statistic accounted for 108 of 129 public universities in the Football Bowl Subdivision. 36. “NFL Reaches $14 Billion, Fueled by Media,” SportsBusiness Journal, March 6, 2017. 37. Rich Luker, Luker on Trends, 2016. 38. Liverocksolid.com
39. HipFootball.com 40. “Not Safe for Children? Football’s Leaders Make Drastic Changes to Youth Game,” New York Times, Jan. 31, 2017. 41. "Pop Warner Settles Wrongful Death Lawsuit, Could Open 'Floodgates,'" USA Today Sports, March 9, 2016. 42. "Moms Take on Football, Suing Pop Warner For Their Sons' Head Traumas, Deaths," San Diego Union Tribune, Jan. 28, 2018. 43. "North Carolina Coach Larry Fedora Rants About CTE and Says Football is 'Under Attack,'" USA Today Sports, July 18, 2018. 44. “Dwight D. Eisenhower, At Ease: Stories I Tell to Friends,” Garden City, NY: Doubleday, 1967. 45. “School Sports Provide Lessons in How to Live,” New York Times, Dec. 22, 2015. 46. "Concussion Concerns Affect Youth Football," San Diego Union Tribune, Nov. 26, 2017. 47. Football Mortality Among Boys, JAMA Network, Dec. 19, 2007. 48. "Drew Brees is Starting a Flag Football League to 'Save the Game of Football,'" CBSSports.com, June 28, 2017. 49. "Saints QB Drew Brees Launching Co-Ed Youth Flag Football League," ESPN.com, June 28, 2017.
26 The Aspen Institute | Sports & Society Program 10/12/2018 Page 199 TO LEARN MORE ABOUT THIS SUBJECT: Watch our Future of Football panel discussion at as.pn/FutureofFootball
ABOUT THE ASPEN INSTITUTE The Aspen Institute is a nonpartisan forum for values-based leadership and the exchange of ideas. Based in Washington, DC, the Institute also has campuses in Aspen, CO, and on the Wye River in eastern Maryland, and maintains offices in New York City and several other cities. www.AspenInstitute.org
ABOUT SPORTS & SOCIETY The mission of the Sports & Society Program is to convene leaders, facilitate dialogue and inspire solutions that help sports serve the public interest. The program provides a venue for thought leadership where knowledge can be deepened and breakthrough strategies explored on a range of issues. Its signature initiative is Project Play, which develops, applies and shares knowledge that helps stakeholders build healthy communities through sports. www.SportsAndSociety.org
ABOUT FUTURE OF SPORTS Launched in 2018, the quarterly conversation series aims to think through the biggest ideas at the intersection of sport and society. We convene diverse thought leaders, and ask, "What if ...?" The goal is to demystify and advance dialogue on paradigm shifts that could shape the future of sports. as.pn/FutureofSports
CONTACT THE ASPEN INSTITUTE SPORTS & SOCIETY PROGRAM Twitter: @AspenInstSports, #AspenSportsLab Facebook.com/AspenInstSports Email: [email protected] 202.736.2916
10/12/2018 Page 200 10/1/2018 How many young people die playing football? - CNN
Deaths on college and high school football fields are a rare -- but reliable -- tragedy
By AJ Willingham, CNN
Updated 10:37 AM ET, Sat September 22, 2018
(CNN) — This fall, more than a million kids, teens and young men will line up on the hash marks for another season of football. Millions more will watch, either as rabid fans or, increasingly, as concerned parents and loved ones.
It isn't just the looming threat of broken bodies or chronic brain injuries that gives people pause when it comes to the risks associated with football. Almost every year, a few young people lose their lives on the field or as an indirect result of their actions on it.
10/12/2018 Page 201 https://www.cnn.com/2018/09/21/health/football-deaths-season-injuries-high-school-college-trnd/index.html 3/10 10/1/2018 How many young people die playing football? - CNN
How many football players are there in the U.S.? 3,000,000 youth* 1,100,000 high school 100,000 post high school**
*Defined as “non-school, youth football but organized and using full protective equipment” **NFL, NCAA, National Association of Intercollegiate Athletics (NAIA), National Junior College Athletic Association (NJCAA), Arena Football and Semi- professional football as of 2012
Source: NCCSIR, National Federation of State High School Associations (NFHS), USA Football, National Operating Committee for Standards in Athletic Equipment (NOCSAE) Graphic: Paul Martucci, CNN
In June, University of Maryland o ensive lineman Jordan McNair died as a result of heatstroke he developed during a practice in May. His death devastated the university's football community, and inquiries into the school's handling of his treatment are ongoing.
It's a rare but reliable tragedy: rare in that the number of deaths at any level of organized football is a tiny fraction of the overall number of participants; reliable because the deaths happen for specific and
10/12/2018 Page 202 https://www.cnn.com/2018/09/21/health/football-deaths-season-injuries-high-school-college-trnd/index.html 4/10 10/1/2018 How many young people die playing football? - CNN recurring reasons, and program organizers across the board have to constantly consider ways to make this inherently brutal sport less so.
Football deaths at any level are very rare
When it comes to numbers, the National Center for Catastrophic Sport Injury Research publishes one of the most widely referenced annual studies on the subject of football deaths in the US. Its surveys use reports from coaches and other athletic department sta members across the country, as well as media reports and independent research.
According to its 2017 report, more than 4 million kids and young people played some form of organized football last year. Of them, 13 reportedly died as a direct or indirect result of play: four direct and nine indirect. The survey defines "direct" as traumatic results of on-field play: spinal cord injuries, organ lacerations, head injuries and the like. "Indirect" deaths are caused by systemic failures because of exertion: heatstroke and most incidences of cardiac arrest, for example.
That means, for 2017, the the rate of direct fatalities was 0.095 per 100,000 players, and the rate of indirect fatalities was 0.21 per 100,000 players.
Historically, 2017 was not a particularly deadly year, nor was it a particularly non-deadly one.
10/12/2018 Page 203 https://www.cnn.com/2018/09/21/health/football-deaths-season-injuries-high-school-college-trnd/index.html 5/10 10/1/2018 How many young people die playing football? - CNN
Reported football-related fatalities since 2000 “Direct” refers to traumatic fatalities that occur directly through physical participation in football. “Indirect” refers to systemic fatalities that occur due to exertion or secondary complications.
Indirect
Direct
24
22
20 9 3 18
16 1 7 6 3 5 7 14 6 3 5 12 5 3 4 8 4 10 3 18 8 3 16 15 13 13 6 12 12 12 11 11 11 10 10 4 9 9 9 7 7 2
2000 2001 2002 2003 2004 2005 2006 2007 10/12/20182008 2009 2010 2011 2012 2013 2014 2015 2016Page2017 204 https://www.cnn.com/2018/09/21/health/football-deaths-season-injuries-high-school-college-trnd/index.html 6/10 10/1/2018 How many young people die playing football? - CNN
Figures combine deaths from organized youth, pro, semi-pro, middle and high school, and college levels.
Source: NCCSIR Throughout the years, a few general trends can be seen: Deaths tend to occur more frequently at the high school and college levels than youth and professional, and indirect deaths tend to significantly outnumber direct deaths. According to the center, twice as many indirect deaths have been recorded than direct deaths since 1990.
Deaths can occur as a result of injury or exertion
Perhaps because of the rising awareness of chronic traumatic encephalopathy, called CTE, a lot of concern seems to focus on brain and spinal injuries as the biggest risk in the sport. In reality, football- related deaths have several causes.
In 2017, the four reported direct deaths were all due to brain injuries. The majority of the deaths that year -- the nine indirect cases -- were due to heatstroke (hyperthermia) and exertion-related cardiac arrest. Subarachnoid hemorrhage (bleeding on the brain) is another indirect cause of death.
Rarely, football players die as a result of injuries to internal organs. (Three instances were recorded between 1990 and 2010.)
10/12/2018 Page 205 https://www.cnn.com/2018/09/21/health/football-deaths-season-injuries-high-school-college-trnd/index.html 7/10 10/1/2018 How many young people die playing football? - CNN
Suspected causes of direct and indirect football deaths in 2017 There were 13 reported cases of football-related deaths in 2017.
Direct: Unspecified traumatic brain injury 3 Cervical spinal cord/nerve injury 1 Indirect: Cardiac arrest* 5 Heat stroke 3 Subarachnoid hemorrhage 1 TOTAL 13
*Not caused by disruption in hearth rhythm by blunt force (commotio cordis)
Source: NCCSIR Graphic: Paul Martucci, CNN
Although there are risks involved in any sport and any type of exertion, the physical and contact-heavy nature of football means players are particularly at risk for brain and spinal cord injury.
"Football is a collision sport; traumatic injuries are frequent and can be fatal," says a 2017 paper from the US Centers for Disease Control and Prevention.
The paper examined football-related deaths between 2005 and 2014 and found 28 brain- or spinal cord- related injuries that resulted in death. Of these, 24 occurred at the high school level and four at the college level. (The number of high school football participants is more than 10 times the number of college football participants, it says.)
In comparison, the National Center for Catastrophic Sport Injury Research found 34 instances of heatstroke death during that period.
Player safety is an ongoing challenge 10/12/2018 Page 206 https://www.cnn.com/2018/09/21/health/football-deaths-season-injuries-high-school-college-trnd/index.html 8/10 10/1/2018 How many young people die playing football? - CNN Since the nature of the sport is so brutal, it is an ongoing challenge among health organizations, football organizations and schools and colleges to maintain e ective safety policies and practices. And of course, avoiding death isn't the only aim; traumatic brain and spinal injuries, exertion injuries and other physical consequences don't need to kill to be devastating.
Key football safety policy changes since 1976
1976: Tackling with the crown of the head (“spearing”) is banned by the NFL, NCAA and NFHS 1978: A new technical standard for helmets is mandated by the NCAA 1980: The 1978 helmet technical standard is adopted by high school football (NFHS) 2005: The NCAA strengthens spearing rule, removing reference to intentionality 2007: The NFHS strengthens its illegal helmet contact rules, banning helmet contact with players on ground or defenseless players 2013: The NCAA institutes an automatic ejection rule for targeting/spearing 2014: The NFHS penalizes targeting, defining it as “an act of taking aim and initiating contact to an opponent above the shoulders with the helmet, forearm, hand, fist, elbow or shoulders.” 2018: The NFL institutes new helmet rule penalizing the lowering of the head and avoidable helmet contact
Source: NIH, NCCSIR, ESPN, NFHS, NFL Graphic: Paul Martucci, CNN
Player safety in high school, college and pro football organizations has gone through decades of evolution, often with similar measures in relatively the same time frame. In recent years, the NCAA and high school organizations have tightened their definition of and penalties for "spearing" or "targeting," tackling moves that lead with the helmet and pose a serious brain and spinal injury risk to both the tackler and the target.
10/12/2018 Page 207 https://www.cnn.com/2018/09/21/health/football-deaths-season-injuries-high-school-college-trnd/index.html 9/10 10/1/2018 How many young people die playing football? - CNN Experts suggest vigilance, education and prompt care
Shoring up conduct on the field is only one part of the puzzle when it comes to reducing football deaths and injuries. Recommendations from the CDC and other organizations on how to deal with concussions and exertion-related conditions point to a combination of vigilance, awareness and education.
In early September, the CDC released new guidelines for health care providers about identifying and handling concussions in children. Several Get CNN Health's weekly involve the awareness and notification of a child's teachers, coaches and newsletter other guardians so that a child's recovery can be "monitored collaboratively."
Sign up here to get The Results Are In The CDC also has a partnership with the National Federation of State High with Dr. Sanjay Gupta every Tuesday from School Associations for online concussion training. The National Center the CNN Health team. for Catastrophic Sport Injury Research recommends physicals for all football participants, proper conditioning exercises and an open channel of communication between players and athletic leaders so any signs of distress -- whether from concussions, dehydration or hyperthermia -- can be immediately addressed.
10/12/2018 Page 208 https://www.cnn.com/2018/09/21/health/football-deaths-season-injuries-high-school-college-trnd/index.html 10/10 18-307
Address the Obesity Crisis through a Soda Tax
Submitted by: Richmond Academy of Medicine
WHEREAS, more than two-thirds of Americans are clinically obese or overweight, and numerous medical studies indicate those individuals are at a significantly higher risk of developing cancer, diabetes, heart disease, and other related medical ailments, and
WHEREAS, rising consumption of sugary drinks has been a major contributor to the obesity epidemic, and
WHEREAS, studies have shown that reducing sugary-sweetened beverages - beverages – defined by the CDC as any liquids that are sweetened with various forms of added sugars like brown sugar, corn sweetener, corn syrup, dextrose, fructose, glucose, high-fructose corn syrup, honey, lactose, malt syrup, maltose, molasses, raw sugar and sucrose with examples including but not limited to regular soda (not sugar-free), fruit drinks, sports drinks, energy drinks, sweetened waters, and coffee and tea beverages with added sugars ---- can lead to better weight control among those who are initially overweight, and
WHEREAS, a 2011 study in the journal Preventive Medicine concluded that “a modest tax on sugar-sweetened beverages could both raise significant revenues and improve public health by reducing obesity,” and
WHEREAS, the AMA recognizes that taxes on beverages with added sweeteners are one means by which consumer education campaigns and other obesity-related programs could be financed in a stepwise approach to addressing the obesity epidemic, and
WHEREAS, in 2014, Berkeley, California became the first city in the United States to Pass a tax on sugar-sweetened beverages with the goal of citizens cutting back on consumption and eventually helping to chip away at the rates of diseases like obesity and type 2 diabetes, and
WHEREAS, that tax, which tacked on one cent per fluid ounce on beverages with added caloric sweeteners like sodas, energy drinks and sweetened fruit drinks appears to be working, according to a report published in the PLOS Journal; and
WHEREAS, researchers looked at whether the tax impacted the buying behaviors of Berkeley residents and found that one year after the tax took effect, sales of sugar- sweetened drinks fell by close to 10%, and sales of water increased in Berkeley by about 16%. Sales of unsweetened teas, milk and fruit juices also went up, suggesting people were substituting their sugary drinks with healthier alternatives; and
WHEREAS, since Berkeley, California institutes a tax on sugar-sweetened beverages, several other cities have followed their lead with some variation of a soda tax including Boulder, San Francisco, Oakland, Cook County, and Philadelphia, therefore be it
10/12/2018 Page 209 RESOLVED, that the Medical Society of Virginia support a statewide tax on sugar-sweetened beverages as a measure to help decrease obesity, and be it further
RESOLVED, that the funds generated by such a tax would should be used to develop effective and evidence-based approaches to addressing childhood obesity or health education.
10/12/2018 Page 210 Staff Analysis – Resolution 18-307: Address the Obesity Crisis Through a Soda Tax Submitted by Richmond Academy of Medicine
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients The resolution asks MSV to Raise MSV does not have Benefits Staff recommends amending and support a state tax on sugar- perceived value policy specific to food or Consumption taxes have adopting: sweetened beverages. of physicians beverage taxes. demonstrated a related
decrease in consumption. The American Heart Association However, MSV does have Decreased consumption RESOLVED, that the Medical Society supports taxing sugar-sweetened policies related to other of sugar sweetened of Virginia support a statewide tax on beveragesi taxes: beverages would have a sugar-sweetened beverages as a
positive health impact for measure to help decrease obesity, and Adults who drink one soda or 40.20.11- Tobacco patients and reduce be it further more daily are 27% more likely to Sales Tax healthcare costs be overweight or obese than 40.2.02- Sales Tax RESOLVED, that the funds generated adults who do not, even after Increase for Alcohol Drawbacks by such a tax would should be used to accounting for poverty status and All sugar sweetened develop effective and evidence-based race/ethnicityii beverage taxes in the approaches to addressing childhood
MSV has several policies U.S. are local taxes— obesity or health education. A 10% price increase might on obesity: there are currently state- decrease consumption of less level taxes healthy foods and beverages by 10.1.13- Insurance This is a regressive tax 8%iii Coverage for Surgical that would have the
and Medical Treatment largest impact on low As of June 2017, no states had a of Obesity and Morbid income communities sugar sweetened beverage tax, Obesity although 7 localities had 10.1.15- Improve implemented the tax.iv Obesity Medicare &
Insurance Coverage
10/12/2018 Page 211 40.20.11- Tobacco Sales Tax The Medical Society of Virginia condemns the introduction of new tobacco products and promotions particularly those designed to attract young people, and supports the ban such of products and promotions.
The Medical Society of Virginia strongly supports a significant tobacco tax increase as a measure to reduce tobacco use in our population. Revenue from such a tax should be used to support health related programs for the citizens in the Commonwealth, tobacco education in elementary and middle schools, funding for childhood respiratory and cardiovascular disease prevention and treatment, as well as subsidizing tobacco farmers who choose to harvest nontobacco crops.
The Medical Society of Virginia strongly supports a tobacco tax equivalent to at least the national average as a measure to reduce tobacco use in our population. The Medical Society of Virginia supports legislation which would require that the funds generated by an increase in the state tobacco tax be used to support health related programs for the citizens of the Commonwealth.
Amended by Substitution 10/22/2017
40.2.02- Sales Tax Increase for Alcohol Date: 10/31/1992
The Medical Society of Virginia supports legislation to raise the state tax on alcohol and to use the monies generated through this increase in tax to promote preventive medicine, public health and primary care.
Reaffirmed 11/2/2012
10.1.13- Insurance Coverage for Surgical and Medical Treatment of Obesity and Morbid Obesity Date: 11/7/2004
The Medical Society of Virginia affirms the need for government and commercial insurance coverage of legitimate medical diagnostic evaluation and treatments for obesity. The Medical Society of Virginia supports mandated insurance coverage for those surgical and medical treatments for morbid obesity that are nationally recognized as effective for the long-term reversal of morbid obesity.
10/12/2018 Page 212 Reaffirmed 11/5/2006 Reaffirmed 10/16/2016
10.1.15- Improve Obesity Medicare & Insurance Coverage Date: 10/22/2017
The Medical Society of Virginia through its delegation to the AMA supports coverage for healthcare costs associated with medical, surgical, nutritional and behavioral treatment interventions for patients diagnosed with obesity. i https://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_474846.pdf ii https://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_474846.pdf iii https://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_474846.pdf iv https://www.sciencedaily.com/releases/2017/06/170607142602.htm
10/12/2018 Page 213 18-308
Firearm Risk Harm Reduction
Submitted by: Richmond Academy of Medicine
WHEREAS, MSV Policy 40.9.02 expresses support for future laws and regulations relating to firearms which would promote trauma control and increased public safety, and
WHEREAS, MSV policy 40.9.05 supports gun violence restraining orders as a mechanism to decrease gun related suicides and homicides.
WHEREAS, research indicates that states that restricted access to firearms by abusers under restraining orders saw an 8% decrease in intimate partner homicides (Vigdor, et al), and
WHEREAS, MSV Policy 40.23.01 opposes any type of domestic violence and supports the inclusion of educational material regarding resources, criminal laws, and prevention in government publications related to marriage and families, and
WHEREAS, in the 2018 Virginia General Assembly session, SB 732 as introduced would prohibit “a person who has been convicted of stalking, sexual battery, assault and battery of a family or household member, brandishing a firearm, or two or more convictions of assault and battery from possessing or transporting a firearm” but this bill was passed by indefinitely, and
WHEREAS, research indicates that individuals with prior misdemeanor convictions are at greater risk of future violence and firearm-related crimes (Wintemute, et al), and
WHEREAS, District of Columbia vs. Heller upheld the right of individual states to impose restrictions on gun ownership, therefore be it
RESOLVED, that the Medical Society of Virginia reaffirm policy 40.9.05; and furthermore be it
RESOLVED, that the Medical Society of Virginia support prohibiting gun ownership by individuals convicted of prior violent misdemeanors; and furthermore be it
RESOLVED, that the Medical Society of Virginia oppose requiring reciprocal concealed carry permits in Virginia.
10/12/2018 Page 214 Staff Analysis – Resolution 18-308: Firearm Risk Harm Reduction Submitted by Richmond Academy of Medicine
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
This resolution asks MSV to support Empower MSV has a Benefits Given the complex nature and prohibiting gun ownership by individuals physicians to policy related to Decreasing gun magnitude of the issue, staff has convicted of prior violent misdemeanors and manage change gun violence ownership among certain provided the following insights for oppose reciprocal concealed carry permits. restraining populations is thought to consideration: orders: 40.9.05. reduce the risk for Gun Violence Restraining Orders possible injury and/or MSV’s existing gun policies are Gun violence restraining orders allow law MSV has no death broad. This leaves room for enforcement to remove guns from persons policies related interpretation by the executive who are a threat of violence to themselves or to specifically Drawbacks committee during General others. prohibiting gun Laws regarding gun Assembly sessions to determine MSV has existing policy 40.9.05 supporting ownership or ownership are politically whether the MSV’s policy supports GVROs. AMA supports GVROs in policy H- opposing sensitive and are difficult specific gun-related legislation. 145.996 requiring to garner bipartisan Moving forward, it would be helpful Virginia does not have a GVRO law. HB 1758 reciprocal support. for the MSV legislative team and was introduced during the 2018 General concealed carry the executive committee if the HOD Assembly session. permits in Opponents will likely have gives specific guidance related to Virginia. concerns about due specific gun policy options. Violent Misdemeanors process, the power of Misdemeanors are defined in § 18.2-8 as all government officials and Staff suggests incorporating any offenses that are not punishable with death or Please see the potential second gun control resolutions into 40.9.01 confinement in a state correctional facility next page for a amendment violations. as a way to provide additional (felonies). Violent misdemeanors are not list of MSV’s clarity as to specific control defined in the Virginia code. Federal law 18 existing policies methods. U.S.C. § 922(g)(9) prohibits anyone convicted related to of a felony and anyone subject to a domestic firearms. violence protective order or a misdemeanor crime of domestic violence from possessing a firearm. Some states have begun passing similar laws to strengthen their enforcement capacity. Virginia does not have this law.
As of 2017, seven states had passed laws banning those convicted of domestic violence to obtain firearms, with 3 of them (NJ, ND, RI) requiring those convicted to turn their guns over to law enforcement.i
As of 2017, 27 states have passed laws
10/12/2018 Page 215 curtailing access to guns by people convicted of domestic violence offenses or subject to protective orders. Of these, 17 states have laws in place requiring them hand over their guns to law enforcement.ii
AMA policy H-145.972 supports prohibiting persons who are under domestic violence restraining orders, convicted of misdemeanor domestic violence crimes or stalking, from possessing or purchasing firearms
Reciprocal Concealed Carry Reciprocal concealed carry permits refers to a state that recognizes permits for the concealed carry of a handgun issued in another state. Twenty states currently honor all US issued concealed carry permits, including Virginia (§ 18.2-308.014). At the federal level, H.R. 38 Concealed Carry Reciprocity Act of 2017, which aimed to create a national concealed carry reciprocity law, passed the House but not the Senate.
AMA policy H-145.985 opposes concealed carry reciprocity federal legislation
40.9.01- Control of Violent Use of Firearms Date: 11/11/1989 The Medical Society of Virginia supports methods to control the misuse and violent use of firearms. Reaffirmed 10/25/2009 Reaffirmed 10/26/2014 Reaffirmed 10/22/2017
40.9.02- Support for Firearm Laws Promoting Increased Public Safety Date: 11/2/2012 The Medical Society of Virginia opposes repeal of existing state or federal laws and regulations that promote safety and responsibility in the purchase, possession or use of firearms and
10/12/2018 Page 216 ammunition. The Medical Society of Virginia supports future laws and regulations relating to firearms which would promote trauma control and increased public safety. Reaffirmed 10/26/2014 Reaffirmed 10/22/2017
40.9.03– MSV School Gun Violence Deterrence Initiative Date: 5/6/2017 The Medical Society of Virginia Board of Directors and relevant stakeholders will engage in an exploratory discussion on the enhancement of protective measures for safety and the deterrence of gun violence in the Commonwealth of Virginia. The coalition formed by the Medical Society of Virginia will provide a model for collaborative leadership nationally in our mutual desire to deter gun violence in our nation’s schools.
40.9.04- Child Firearm Injury Prevention The Medical Society of Virginia supports public education programs to reduce injuries to children from firearms as well as the dangers and legal liabilities of recklessly leaving loaded, unsecured firearms accessible to children. Further, the Society will the Medical Society of Virginia will cooperate and collaborate with interested advocacy groups regarding child firearm injury prevention. The Medical Society of Virginia supports requiring safety devices to be sold with each gun sold in Virginia, either at a regulated gun store or through other means such as gun shows. Amended by Substitution 10/22/2017
40.9.05- Gun Violence Restraining Orders Date: 10/22/2017 The Medical Society of Virginia supports gun violence restraining orders as a mechanism to decrease gun related suicides and homicides. i https://www.washingtonpost.com/national/2017/09/21/states-move-to-restrict-domestic-abusers-from-carrying-guns/?utm_term=.f07604cc20e9 ii https://www.washingtonpost.com/national/2017/09/21/states-move-to-restrict-domestic-abusers-from-carrying-guns/?utm_term=.f07604cc20e9
10/12/2018 Page 217 18-309
Limit Sales of Bump Stocks
Submitted by: Richmond Academy of Medicine
WHEREAS, MSV Policy 145.003 expresses support for future laws and regulations relating to firearms which would promote trauma control and increased public safety, and
WHEREAS, the American Academy of Family Physicians, American College of Physicians and the American Academy of Pediatrics, American College of Obstetrics and Gynecology and American Psychiatric Association on 2/16/18 renewed their call on government to act on the public health epidemic of gun violence including placing constitutionally appropriate restrictions on the manufacture and sale of assault weapons and large capacity magazines, and the American College of Surgeons on 2/28/18 reiterated their continued support of restrictions on assault weapons and large-capacity ammunition clips, and
WHEREAS, District of Columbia vs. Heller upheld the right of individual states to impose restrictions on gun ownership, therefore be it
RESOLVED, that the Medical Society of Virginia will support limits to the sale and ownership of bump stocks.
10/12/2018 Page 218 Staff Analysis – Resolution 18-309: Limit Sales of Bump Stocks Submitted by Richmond Academy of Medicine
Strategic Background Plan MSV Policy Impact on Physicians/Patients Staff Recommendation (RISE)
This resolution asks MSV to support limits to the Empower MSV has no Benefits Given the complex nature sale and ownership of bump stocks. physicians to policies specifically Limiting the volume and and magnitude of the issue, manage related to bump capacity of firearms is thought staff has provided the A bump stock is a modification that allows change stocks. to reduce the risk for possible following insights for semiautomatic guns to behave similarly to injury and/or death consideration: automatic gunsi Please see the next page for a list of Drawbacks MSV’s existing gun Federal law currently allows bump stocks, MSV’s existing Laws regarding gun policies are broad. This although the U.S. Department of Justice and the policies related to ownership are politically leaves room for U.S. Bureau of Alcohol, Tobacco, Firearms, and firearms. sensitive and are difficult to interpretation by the Explosives (ATF) are currently reviewing the garner bipartisan support. executive committee classification of bump stocks.ii during General Assembly Opponents will likely have sessions to determine Virginia does not have a law related to bump concerns about due process, whether the MSV’s policy stocks. Virginia has seen introduced legislation the power of government supports specific gun- related to bump stocks, including HB 41 officials and potential second related legislation. introduced in 2018. amendment violations. Moving forward, it would be helpful for the MSV The following states have laws banning or legislative team and the reducing access to bump stocksiii iv: executive committee if o Massachusetts the HOD gives specific o New Jersey guidance related to o Washington specific gun policy o California options. o New York o Maryland Staff suggests o Hawaii incorporating any gun o Connecticut control resolutions into o Delaware 40.9.01 as a way to o Rhode Island provide additional clarity o Maryland as to specific control methods. 21 states have considered or are considering bump stock bansv
The AMA has policy opposing the sale of bump stocksvi
10/12/2018 Page 219 40.9.01- Control of Violent Use of Firearms Date: 11/11/1989 The Medical Society of Virginia supports methods to control the misuse and violent use of firearms.
Reaffirmed 10/25/2009 Reaffirmed 10/26/2014 Reaffirmed 10/22/2017
40.9.02- Support for Firearm Laws Promoting Increased Public Safety Date: 11/2/2012 The Medical Society of Virginia opposes repeal of existing state or federal laws and regulations that promote safety and responsibility in the purchase, possession or use of firearms and ammunition. The Medical Society of Virginia supports future laws and regulations relating to firearms which would promote trauma control and increased public safety. Reaffirmed 10/26/2014 Reaffirmed 10/22/2017
40.9.03– MSV School Gun Violence Deterrence Initiative Date: 5/6/2017 The Medical Society of Virginia Board of Directors and relevant stakeholders will engage in an exploratory discussion on the enhancement of protective measures for safety and the deterrence of gun violence in the Commonwealth of Virginia. The coalition formed by the Medical Society of Virginia will provide a model for collaborative leadership nationally in our mutual desire to deter gun violence in our nation’s schools.
40.9.04- Child Firearm Injury Prevention The Medical Society of Virginia supports public education programs to reduce injuries to children from firearms as well as the dangers and legal liabilities of recklessly leaving loaded, unsecured firearms accessible to children. Further, the Society will the Medical Society of Virginia will cooperate and collaborate with interested advocacy groups regarding child firearm injury prevention. The Medical Society of Virginia supports requiring safety devices to be sold with each gun sold in Virginia, either at a regulated gun store or through other means such as gun shows. Amended by Substitution 10/22/2017
40.9.05- Gun Violence Restraining Orders Date: 10/22/2017 The Medical Society of Virginia supports gun violence restraining orders as a mechanism to decrease gun related suicides and homicides.
10/12/2018 Page 220 i https://abcnews.go.com/US/atf-save-bump-stock-owners-maryland-ban/story?id=55073200 ii U.S. Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF) iii http://www.ncsl.org/Portals/1/Documents/magazine/articles/2018/SL_0418-Trends.pdf iv https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2018/05/18/so-states-ban-bump-stocks-now-how-do-they-enforce-the-law v http://www.ncsl.org/Portals/1/Documents/magazine/articles/2018/SL_0418-Trends.pdf vi https://policysearch.ama-assn.org/policyfinder/detail/bump%20stocks?uri=%2FAMADoc%2FHOD.xml-0-550.xml
10/12/2018 Page 221 18-310
Limit Sales of Firearms
Submitted by: Richmond Academy of Medicine
WHEREAS, MSV Policy 145.003 expresses support for future laws and regulations relating to firearms which would promote trauma control and increased public safety, and
WHEREAS, MSV Policy 515.001 opposes any type of domestic violence and supports the inclusion of educational material regarding resources, criminal laws, and prevention in government publications related to marriage and families, and
WHEREAS, the American Academy of Family Physicians, American College of Physicians and the American Academy of Pediatrics, American College of Obstetrics and Gynecology and American Psychiatric Association on 2/16/18 renewed their call on government to act on the public health epidemic of gun violence including placing constitutionally appropriate restrictions on the manufacture and sale of assault weapons and large capacity magazines, and the American College of Surgeons on 2/28/18 reiterated their continued support of restrictions on assault weapons and large-capacity ammunition clips, and
WHEREAS, District of Columbia vs. Heller upheld the right of individual states to impose restrictions on gun ownership, therefore be it
RESOLVED, that the Medical Society of Virginia will support limits to the sale and ownership and firearms with features designed to increase their rapid firing ability, as defined in H.R. 3355 of the 103rd Congress.
10/12/2018 Page 222 Staff Analysis – Resolution 18-310: Limit Sales of Firearms Submitted by Richmond Academy of Medicine
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
This resolution asks MSV to Empower MSV has no policies Benefits Given the complex nature and support limits to the sale and physicians to specifically related to Limiting the volume and magnitude of the issue, staff has ownership and firearms with manage firearms with features capacity of firearms is provided the following insights for features designed to increase change designed to increase their thought to reduce the risk consideration: their rapid firing ability, rapid firing ability for possible injury and/or death MSV’s existing gun policies are H.R. 3355 of the 103rd Congress Please see the next page broad. This leaves room for amended the Federal criminal for a list of MSV’s existing Decreasing gun interpretation by the executive code to prohibit the manufacture, policies related to firearms. ownership among certain committee during General transfer, or possession of a populations is thought to Assembly sessions to determine semiautomatic assault weapon whether the MSV’s policy supports reduce the risk for (SAW) as defined or listed under specific gun-related legislation. the Act. possible injury and/or Moving forward, it would be helpful death for the MSV legislative team and The Act definition of the executive committee if the semiautomatic assault weapons HOD gives specific guidance is included on the next pagei. Drawbacks related to specific gun policy This ban was passed in 1994 Laws regarding gun options. and expired in 2004.ii ownership are politically sensitive and are difficult Staff suggests incorporating any 7 states ban assault weaponsiii: to garner bipartisan gun control resolutions into 40.9.01 CA, NY, MA, NJ, CT, MD, DCiv support. as a way to provide additional (see citation for definition of clarity as to specific control assault weapon in this context) Opponents will likely methods. have concerns about due process, the power of government officials and potential second amendment violations
10/12/2018 Page 223 Definitions from H.R. 3355
(b) DEFINITION OF SEMIAUTOMATIC ASSAULT WEAPON.—Section 921(a) of title 18, United States Code, is amended by adding at the end the following new paragraph: ‘‘(30) The term ‘semiautomatic assault weapon’ means— ‘‘(A) any of the firearms, or copies or duplicates of the firearms in any caliber, known as— ‘‘(i) Norinco, Mitchell, and Poly Technologies Avtomat Kalashnikovs (all models); ‘‘(ii) Action Arms Israeli Military Industries UZI and Galil; ‘‘(iii) Beretta Ar70 (SC–70); ‘‘(iv) Colt AR–15; ‘‘(v) Fabrique National FN/FAL, FN/LAR, and FNC; ‘‘(vi) SWD M–10, M–11, M–11/9, and M–12; ‘‘(vii) Steyr AUG; ‘‘(viii) INTRATEC TEC–9, TEC–DC9 and TEC–22; and ‘‘(ix) revolving cylinder shotguns, such as (or similar to) the Street Sweeper and Striker 12; ‘‘(B) a semiautomatic rifle that has an ability to accept a detachable magazine and has at least 2 of— ‘‘(i) a folding or telescoping stock; ‘‘(ii) a pistol grip that protrudes conspicuously beneath the action of the weapon; ‘‘(iii) a bayonet mount; ‘‘(iv) a flash suppressor or threaded barrel designed to accommodate a flash suppressor; and ‘‘(v) a grenade launcher; ‘‘(C) a semiautomatic pistol that has an ability to accept a detachable magazine and has at least 2 of— ‘‘(i) an ammunition magazine that attaches to the pistol outside of the pistol grip; ‘‘(ii) a threaded barrel capable of accepting a barrel extender, flash suppressor, forward handgrip, or silencer; ‘‘(iii) a shroud that is attached to, or partially or completely encircles, the barrel and that permits the shooter to hold the firearm with the nontrigger hand without being burned; ‘‘(iv) a manufactured weight of 50 ounces or more when the pistol is unloaded; and ‘‘(v) a semiautomatic version of an automatic firearm; and ‘‘(D) a semiautomatic shotgun that has at least 2 of— ‘‘(i) a folding or telescoping stock; ‘‘(ii) a pistol grip that protrudes conspicuously beneath the action of the weapon; ‘‘(iii) a fixed magazine capacity in excess of 5 rounds; and ‘‘(iv) an ability to accept a detachable magazine.’’
(b) DEFINITION OF LARGE CAPACITY AMMUNITION FEEDING DEVICE.—Section 921(a) of title 18, United States Code, as amended by section 110102(b), is amended by adding at the end the following new paragraph: ‘‘(31) The term ‘large capacity ammunition feeding device’— ‘‘(A) means a magazine, belt, drum, feed strip, or similar device manufactured after the date of enactment of the Violent Crime Control and Law Enforcement Act of 1994 that has a capacity of, or that can be readily restored or converted to accept, more than 10 rounds of ammunition; but ‘‘(B) does not include an attached tubular device designed to accept, and capable of operating only with, .22 caliber rimfire ammunition.’’. (c) PENALTY.—Section 924(a)(1)(B) of title 18, United States Code, as amended by section 110102(c)(1), is amended by striking ‘‘or (v)’’ and inserting ‘‘(v), or (w)’’. (d) IDENTIFICATION MARKINGS FOR LARGE CAPACITY AMMUNITION FEEDING DEVICES.—Section 923(i) of title 18, United States Code, as amended by section 110102(d) of this Act, is amended by adding at the end the following: ‘‘A large capacity ammunition feeding device manufactured after the date of the enactment of this sentence shall be identified by a serial number that clearly shows that the device was manufactured or imported after the effective date of this subsection, and such other identification as the Secretary may by regulation prescribe. https://www.congress.gov/103/bills/hr3355/BILLS-103hr3355enr.pdf
40.9.01- Control of Violent Use of Firearms Date: 11/11/1989 The Medical Society of Virginia supports methods to control the misuse and violent use of firearms. Reaffirmed 10/25/2009 Reaffirmed 10/26/2014 Reaffirmed 10/22/2017
10/12/2018 Page 224 40.9.02- Support for Firearm Laws Promoting Increased Public Safety Date: 11/2/2012 The Medical Society of Virginia opposes repeal of existing state or federal laws and regulations that promote safety and responsibility in the purchase, possession or use of firearms and ammunition. The Medical Society of Virginia supports future laws and regulations relating to firearms which would promote trauma control and increased public safety. Reaffirmed 10/26/2014 Reaffirmed 10/22/2017
40.9.03– MSV School Gun Violence Deterrence Initiative Date: 5/6/2017 The Medical Society of Virginia Board of Directors and relevant stakeholders will engage in an exploratory discussion on the enhancement of protective measures for safety and the deterrence of gun violence in the Commonwealth of Virginia. The coalition formed by the Medical Society of Virginia will provide a model for collaborative leadership nationally in our mutual desire to deter gun violence in our nation’s schools.
40.9.04- Child Firearm Injury Prevention The Medical Society of Virginia supports public education programs to reduce injuries to children from firearms as well as the dangers and legal liabilities of recklessly leaving loaded, unsecured firearms accessible to children. Further, the Society will the Medical Society of Virginia will cooperate and collaborate with interested advocacy groups regarding child firearm injury prevention. The Medical Society of Virginia supports requiring safety devices to be sold with each gun sold in Virginia, either at a regulated gun store or through other means such as gun shows. Amended by Substitution 10/22/2017
40.9.05- Gun Violence Restraining Orders Date: 10/22/2017 The Medical Society of Virginia supports gun violence restraining orders as a mechanism to decrease gun related suicides and homicides. i https://www.congress.gov/103/bills/hr3355/BILLS-103hr3355enr.pdf ii https://www.washingtonpost.com/graphics/2017/national/assault-weapons-laws/?utm_term=.f391e8e7f027 iii Assault Weapon defined as: The definition of a military-style assault weapon can vary by state, but in general it means any semiautomatic weapon that includes features or attachments “that appear useful in military and criminal applications but unnecessary in shooting sports or self-defense. https://www.washingtonpost.com/graphics/2017/national/assault-weapons-laws/?utm_term=.f391e8e7f027 iv https://www.washingtonpost.com/graphics/2017/national/assault-weapons-laws/?utm_term=.f391e8e7f027
10/12/2018 Page 225 18-311
Limit Sales of Large Capacity Magazines
Submitted by: Richmond Academy of Medicine
WHEREAS, MSV Policy 145.003 expresses support for future laws and regulations relating to firearms which would promote trauma control and increased public safety, and
WHEREAS, the American Academy of Family Physicians, American College of Physicians and the American Academy of Pediatrics, American College of Obstetrics and Gynecology and American Psychiatric Association on 2/16/18 renewed their call on government to act on the public health epidemic of gun violence including placing constitutionally appropriate restrictions on the manufacture and sale of assault weapons and large capacity magazines, and the American College of Surgeons on 2/28/18 reiterated their continued support of restrictions on assault weapons and large-capacity ammunition clips, and
WHEREAS, District of Columbia vs. Heller upheld the right of individual states to impose restrictions on gun ownership, therefore be it
RESOLVED, that the Medical Society of Virginia will support limits to the sale and ownership of large capacity magazines.
10/12/2018 Page 226 Staff Analysis – Resolution 18-311: Limit Sales of Large Capacity Magazines Submitted by Richmond Academy of Medicine
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients
Empower MSV has no policies Given the complex nature and This resolution asks MSV to Benefits support limits to the sale and physicians to specifically related to large- magnitude of the issue, staff has Limiting the volume and ownership of large capacity manage capacity magazines provided the following insights for capacity of firearms is magazines. change consideration: thought to reduce the risk Please see the next page for possible injury and/or High-capacity or large-capacity for a list of MSV’s existing MSV’s existing gun policies are death policies related to firearms. broad. This leaves room for magazines defined as magazines interpretation by the executive that hold a large amount of Drawbacks ammunition, allowing a gun to be committee during General Laws regarding gun fired many times without pausing Assembly sessions to determine i ownership are politically to reload. whether the MSV’s policy supports sensitive and are difficult specific gun-related legislation. to garner bipartisan 8 states ban high-capacity Moving forward, it would be helpful support. magazines: CA, CO, NY, MA, for the MSV legislative team and
NJ, CT, MD, DCii the executive committee if the Opponents will likely HOD gives specific guidance have concerns about due Physician organizations with related to specific gun policy process, the power of supporting policies: American options. government officials and Medical Associationiii potential second Staff suggests incorporating any amendment violations gun control resolutions into 40.9.01 as a way to provide additional clarity as to specific control methods.
10/12/2018 Page 227 40.9.01- Control of Violent Use of Firearms Date: 11/11/1989 The Medical Society of Virginia supports methods to control the misuse and violent use of firearms. Reaffirmed 10/25/2009 Reaffirmed 10/26/2014 Reaffirmed 10/22/2017
40.9.02- Support for Firearm Laws Promoting Increased Public Safety Date: 11/2/2012 The Medical Society of Virginia opposes repeal of existing state or federal laws and regulations that promote safety and responsibility in the purchase, possession or use of firearms and ammunition. The Medical Society of Virginia supports future laws and regulations relating to firearms which would promote trauma control and increased public safety. Reaffirmed 10/26/2014 Reaffirmed 10/22/2017
40.9.03– MSV School Gun Violence Deterrence Initiative Date: 5/6/2017 The Medical Society of Virginia Board of Directors and relevant stakeholders will engage in an exploratory discussion on the enhancement of protective measures for safety and the deterrence of gun violence in the Commonwealth of Virginia. The coalition formed by the Medical Society of Virginia will provide a model for collaborative leadership nationally in our mutual desire to deter gun violence in our nation’s schools.
40.9.04- Child Firearm Injury Prevention The Medical Society of Virginia supports public education programs to reduce injuries to children from firearms as well as the dangers and legal liabilities of recklessly leaving loaded, unsecured firearms accessible to children. Further, the Society will the Medical Society of Virginia will cooperate and collaborate with interested advocacy groups regarding child firearm injury prevention. The Medical Society of Virginia supports requiring safety devices to be sold with each gun sold in Virginia, either at a regulated gun store or through other means such as gun shows. Amended by Substitution 10/22/2017
40.9.05- Gun Violence Restraining Orders Date: 10/22/2017 The Medical Society of Virginia supports gun violence restraining orders as a mechanism to decrease gun related suicides and homicides. i https://www.washingtonpost.com/graphics/2017/national/assault-weapons-laws/?utm_term=.f391e8e7f027 ii https://www.washingtonpost.com/graphics/2017/national/assault-weapons-laws/?utm_term=.f391e8e7f027
10/12/2018 Page 228 iii https://policysearch.ama-assn.org/policyfinder/detail/large%20capacity%20magazines?uri=%2FAMADoc%2FHOD.xml-0-550.xml
10/12/2018 Page 229 18-312
Promote Background Checks on Gun Sales
Submitted by: Richmond Academy of Medicine
WHEREAS, MSV Policy 145.003 expresses support for future laws and regulations relating to firearms which would promote trauma control and increased public safety, and
WHEREAS, MSV Policy 515.001 opposes any type of domestic violence and supports the inclusion of educational material regarding resources, criminal laws, and prevention in government publications related to marriage and families, and
WHEREAS, multiple analysis have demonstrated an inverse relationship between limits on firearm ownership and gun-related death rates, and
WHEREAS, District of Columbia vs. Heller upheld the right of individual states to impose restrictions on gun ownership, therefore be it
RESOLVED, that the Medical Society of Virginia will support uniform/universal background checks for gun sales.
10/12/2018 Page 230 Staff Analysis – Resolution 18-312: Promote Background Checks on Gun Sales Submitted by Richmond Academy of Medicine
Strategic Plan Impact on Background MSV Policy Staff Recommendation (RISE) Physicians/Patients Benefits The Brady Handgun Violence Empower MSV has no policies Given the complex nature and Decreasing gun Prevention Act (1994) imposed physicians to specifically related to magnitude of the issue, staff has ownership among certain federal requirements for manage background checks on gun provided the following insights for populations is thought to background checks on sales by change sales. consideration: reduce the risk for licenses dealers, but not for possible injury and/or private sales or transfers of Please see the next page MSV’s existing gun policies are i death firearms (such as gifts). for a list of MSV’s existing broad. This leaves room for
policies related to firearms. interpretation by the executive Drawbacks Universal background checks committee during General Laws regarding gun aim to prevent purchases by Assembly sessions to determine ownership are politically prohibited possessors as defined whether the MSV’s policy supports sensitive and are difficult by 18 U.S.C. § 922(g) specific gun-related legislation. to garner bipartisan Moving forward, it would be helpful support. Some states have expanded this for the MSV legislative team and
federal requirement to mandate the executive committee if the Opponents will likely background checks for all sales, HOD gives specific guidance have concerns about due also known as universal related to specific gun policy ii process, the power of background checks. options. government officials and
potential second As of January 2017, 19 states Staff suggests incorporating any amendment violations. and D.C. require some form of gun control resolutions into 40.9.01 universal background check.iii as a way to provide additional clarity as to specific control Virginia does not require private methods. sellers (sellers who are not licensed) to initiate a background check when transferring a firearmiv
In 2017, Virginia passed a law (HB 1386/SB 715) expanding voluntary criminal background checks for the private sale of firearms at gun shows. During the first year of this law, 54 voluntary background checks were requested at 77 gun shows, with one denied purchase.v
10/12/2018 Page 231 During the same year, 39,738 mandatory criminal background checks were performed by licensed firearms dealers on their customers at gun shows, with 325 denials.vi
40.9.01- Control of Violent Use of Firearms Date: 11/11/1989 The Medical Society of Virginia supports methods to control the misuse and violent use of firearms. Reaffirmed 10/25/2009 Reaffirmed 10/26/2014 Reaffirmed 10/22/2017
40.9.02- Support for Firearm Laws Promoting Increased Public Safety Date: 11/2/2012 The Medical Society of Virginia opposes repeal of existing state or federal laws and regulations that promote safety and responsibility in the purchase, possession or use of firearms and ammunition. The Medical Society of Virginia supports future laws and regulations relating to firearms which would promote trauma control and increased public safety.
10/12/2018 Page 232 Reaffirmed 10/26/2014 Reaffirmed 10/22/2017
40.9.03– MSV School Gun Violence Deterrence Initiative Date: 5/6/2017 The Medical Society of Virginia Board of Directors and relevant stakeholders will engage in an exploratory discussion on the enhancement of protective measures for safety and the deterrence of gun violence in the Commonwealth of Virginia. The coalition formed by the Medical Society of Virginia will provide a model for collaborative leadership nationally in our mutual desire to deter gun violence in our nation’s schools.
40.9.04- Child Firearm Injury Prevention The Medical Society of Virginia supports public education programs to reduce injuries to children from firearms as well as the dangers and legal liabilities of recklessly leaving loaded, unsecured firearms accessible to children.
Further, the Society will the Medical Society of Virginia will cooperate and collaborate with interested advocacy groups regarding child firearm injury prevention.
The Medical Society of Virginia supports requiring safety devices to be sold with each gun sold in Virginia, either at a regulated gun store or through other means such as gun shows. Amended by Substitution 10/22/2017
40.9.05- Gun Violence Restraining Orders Date: 10/22/2017 The Medical Society of Virginia supports gun violence restraining orders as a mechanism to decrease gun related suicides and homicides. i https://www.rand.org/research/gun-policy/analysis/background-checks.html ii https://www.rand.org/research/gun-policy/analysis/background-checks.html iii https://www.rand.org/research/gun-policy/analysis/background-checks.html iv http://lawcenter.giffords.org/background-checks-in-virginia/ v https://www.roanoke.com/news/virginia/new-law-that-encourages-voluntary-background-checks-at-va-gun/article_f76d228c-679d-5af0-a1ca-790d13bc2dce.html vi https://www.roanoke.com/news/virginia/new-law-that-encourages-voluntary-background-checks-at-va-gun/article_f76d228c-679d-5af0-a1ca-790d13bc2dce.html
10/12/2018 Page 233