The 2022 Legislative Session has been a whirlwind. Election-year politics always brings out highly partisan legislative proposals and this year did not deviate from that norm. There were 657 bills introduced and your CSOM Board engaged in 80 of those. While bills relating to the State’s response to the COVID pandemic and anticipated Supreme Court ruling affecting access to abortion services were abundant, there were other themes running through the health care proposals this year. Those included expanded scopes of practice for non-physician providers, workforce issues – increasing access to health care in rural areas of Colorado, reducing costs of care and mental health care and substance use disorder related issues. Here are a few highlighted bills CSOM was involved with in each of those categories:
Scope of Practice
HB22-1095 – Physician Assistant Collaborative Requirements
The proposal, very similar to last year’s proposal, would have remove formal supervision of physicians assistants by physicians. In lieu of “supervision”, the PAs were asking for “collaboration” for the first 3,000 hours for a newly licensed PA or 2,000 hours for a PA changing specialties. Upon completion of those required hours, the PA would not be required to have any collaborative plan with a physician. Initially the bill would have also allowed an employer to require a physician to collaborate with a PA as a condition of the physician’s employment. With opposition from CSOM and other physician advocacy groups, HB22-1095 failed to pass.
HB22-1233 – Regulation of Optometry
This sunset bill, meaning it was a preplanned review of the regulation of the practice of optometry, made some significant changes to the scope of practice for optometrists. Effective later this summer, the practice of optometry will include non-intraocular injections which do not penetrate the globe, the administration of local anesthetics used in the removal and biopsy of certain eyelid lesions, the incision and curettage of chalazions, simple repairs of eyelid lacerations, corneal cross-linking and laser capsulotomy, laser peripheral iridotomy and laser trabeculoplasty. The laser procedures are restricted to those optometrists who demonstrate competency and meet minimum educational standards. This bill lobbied as intensely as the physician assistants bill noted above was successful and is on the Governor’s desk pending his action. Some physician groups are calling on Governor Polis to veto this bill.
HB22-1005 – Rural Health-care Preceptor Tax Credit
Governor Polis signed this extension of the Rural Health-care Preceptor Tax Credit on June 1. The bill extends the time frame the tax credit is available through January 2033, increases the number of credits available from 200 to 300 tax credits and expands those eligible to apply for the credit beyond MDs, DOs, APRNs, PAs and dentists to include RNs, pharmacists and various licensed mental healthcare providers.
SB22-056 – UNC Osteopathic Medicine Degrees
SB22-056 authorizes the University of Northern Colorado to offer degrees in osteopathic medicine. This bill was necessary to allow UNC to move forward with an osteopathic medical school because current state statute grants the University of Colorado exclusive authority to offer degrees in medicine, dentistry, pharmacy and physical therapy. An exemption was needed to allow for a non-private school to offer degrees in Colorado.
SB22-200 – Rural Provider Stimulus Grant Program
Also signed into law on June 1, this bill aims to utilize federal funds from the “American Rescue Plan Act of 2021” to award grants for both rural access and rural affordability programs. An advisory committee is established within the bill. Such committee will award grants to qualified rural providers in accordance with criteria set forth in the bill. Targeted projects will modernize the information technology infrastructure and increase access to extended hours, telemedicine, new hospital, LTC and SNF beds and additional points of access. $10 million has been set aside for the purposes of these grants.
SB22-226 – Programs to Support Health-care Workforce
SB22-226 was the result of a coalition of health-care provider advocates brought together by the Colorado Hospital Association. The bill took the workforce issues in three categories: the short-term retention of the remaining workforce; medium term goal of supporting those that will take care of us tomorrow; and, long-term recruitment of those that will care for us in the future. This will be an on-going effort, but this made makes great first strides. It focuses on and funds resilience and retention programs and practice based educational grants. $35 million has been appropriated to fund the programs in this proposal.
HB22-1325 – Primary Care Alternative Payment Models
In an attempt to move away from the fee-for-service reimbursement model and towards a model aligning quality, reducing health disparities and ensuring that Coloradoans receive the right care at the right place at an affordable cost, the legislature passed HB22-1325. Housed in the Division of Insurance, this creates a partnership between various departments a divisions of state government, carriers and providers for the purpose of developing the primary care alternative payment model parameters. At a minimum the parameters must include transparent risk adjustments to ensure primary care providers are not disincentivized from accepting certain patients, utilize patient attribution methodologies and align quality measures. Beginning January 2025 carriers must ensure AMPs incorporate these parameters.
This bill grants the Insurance Commissioner vast authority over primary care reimbursement methodologies. It will be an ongoing process with which CSOM will need to be actively involved
Mental Health and Substance Use Disorder
At last count, ten bills had been introduced seeking to expand access to mental health and substance use disorder care. Those bills can be found on the full list of 80 bills followed by CSOM. See link below.) Most hotly debated and broadly covered by the media was the bill aimed at tackling the fentanyl crisis.
HB22-1326 – Fentanyl Accounting and Prevention
Addressing the fentanyl crisis was one of the most hotly debated issues of the session. Harm reduction advocates seeking to get people suffering with SUD into treatment were at odds with law enforcement and families of those who have lost loved ones to accidental fentanyl overdoses who were seeking to get fentanyl off the streets. Neither side was granted their full wish list, but the legislators reached a compromise on the bill and it is on the Governor’s desk.
In an attempt to get fentanyl off the streets this bill makes knowingly possessing any amount of fentanyl less than one gram is a level 1 drug misdemeanor and between one and four grams is a drug felony 4. There are increased penalties for the unlawful distribution, manufacturing, dispensing or sale of any material containing fentanyl carfentanil, benzimidazole opiate or an analog thereof. The bill further creates a special offender designation in certain circumstances.
Treatment and prevention activities included in HB22-1326 are the creation of a fentanyl education and treatment program certain offenders will be eligible to access as well as a fentanyl prevention and education campaign for the general public. Harm reduction grants have been funded at $6 million in fiscal year 2022-23 which includes SUD identification and treatment.
In working with a group of Rocky Vista University, College of Osteopathic Medicine students, we were able to include language in this bill that makes RVU students eligible to receive opiate antagonists through the state’s bulk purchasing program and to administer the opiate antagonist in good faith. $19.7 million was appropriated for this fund.
The changes made in HB22-1326 will be reviewed via an independent study to monitor the effectiveness of these (and other) policy changes.
A complete list of the 80 bills earmarked by CSOM can be found here.
With the close of this 2022 legislative session, we now shift our focus to the elections and preparation for the 2023 session. It is never too early to prepare. The PA bill will return in January 2023 among a laundry list of other bills. Health care and the practice of medicine will always be front and center in political and legislative debates. It is often noted that “if you are not at the table you will be on the table.” CSOM keeps you at the table working to ensure all Colorado osteopathic physicians can fulfill your Osteopathic Pledge.
Provide compassionate, quality care to my patients,
Partner with them to promote health,
Display integrity and professionalism throughout my career,
Advance the philosophy, practice and science of osteopathic medicine,
Continue life-long learning,
Support my profession with loyalty in action, word and deed, and
Live each day as an example of what an osteopathic physician should be.
Below is a link to this week’s legislative report. Many new bills have been introduced. Today is day 73 of 120. The pace of legislative activity is picking up and with just 499 bills introduced so far we expect many and more controversial bills to surface in coming days and weeks. Once the budget is complete, the sprint to adjournment will begin in earnest.In other interesting news:
· Budget. The Joint Budget Committee has completed its work on the 2022-23 budget and will soon send it and accompanying “orbital” bills to the House for introduction on Monday. In an unusual move, JBC member Rep Kim Ransom (R-Parker) took her name off of the budget. Ransom is a conservative Republican who objects to increases in state spending and creation of new programs. By not having her name on the “Long bill”, she will is free to support and offer amendments when the bill is considered in the House. We expect dozens of amendments to be proposed: progressive Democrats may push for more funding for mental health programs, K-12 education, and air quality regulation. Republicans may seek to limit the growth of government, increase funding for public safety programs, and decrease energy costs. After passage in the House late next week, the Long Bill will move to the Senate for consideration the following week.
· Abortion rights. After more than 60 hours of debate HB 1279, “The Reproductive Health Equity Act”, is on its way to the Governor’s desk for signature. The legislation codifies Coloradans’ right to abortion in case the U.S. Supreme Court potentially weakens or overturns Roe v. Wade. Lawmakers made hours of passionate and personal appeals on the Senate floor, arguing both sides of the contentious issue leading up to the vote. Conservative groups have announced they intend to litigate when the bill becomes law. Meanwhile, Democrats plan to enshrine abortion rights in the state constitution with a ballot measure that will be placed before voters in 2024.
· Marijuana in the workplace. HB1152 proposed to limit an employers ability to fire or discipline workers for the use of medical or recreational marijuana, including the use of medical marijuana on the job. The focus of intense lobbying, the bill died 11-1 Thursday in the House Business Affairs and Labor Committee. Colorado’s business community fiercely opposed the bill and testified in opposition. The question of whether using marijuana outside of work hours disqualifies a person for a job or leads to their firing has been churning since voters legalized the sale and use of marijuana with passage of Amendment 64 in 2012. In 2015, a Colorado Supreme Court sided with Dish Network, which fired an employee who tested positive for medical marijuana use in a random drug test. Proposed by a Boulder Democrat this bill was intended to bring clarity to the issue, but failed in every respect.
· Lobbyist spending. Democratic control of state government is generating lots of new lobbying money. Spending on lobbying during the first eight months of the State’s 2022 fiscal year increased 12% from the prior year. Lobbying spending totaled $29.4 million in the first eight months of the 2021-22 fiscal year, from July through February. That’s an increase over the $26.2 million spent during the same time frame in the 2020-21 fiscal year (and $25.4 million in the 2019-20 fiscal year). There are more than 600 lobbyists registered with the Secretary of State, but fewer than one-third of these are active on an ongoing basis.
· Does anyone really know what time it is? Competing bills in the House and Senate propose to eliminate Coloradan’s seasonal adjustment of their clocks by keeping the State on one time throughout the year. HB1297 seeks to make daylight saving time year-round if federal law is changed to allow states to do so. SB135 aims to create a statewide ballot measure to exempt Colorado from recognizing daylight saving time, creating a Mountain Standard Time year-round. Currently federal law prohibits states from implementing year-round daylight saving time although they can use year-round standard time, as Hawaii and Arizona currently do. Colorado lawmakers have tried for more than 30 years to end the flipping back and forth between Mountain Standard Time and daylight saving time. Then-Sen. Bill Schroeder, R-Morrison, led the first effort in 1988. So far efforts to end daylight saving time have been met with fierce push back from the ski industry and broadcasters who said it would disrupt their scheduling and operations. United Airlines, Frontier Airlines, Colorado Ski Country USA, the Colorado Competitive Council, the Colorado Hotel and Lodging Association, Denver Metro Chamber of Commerce and the Tourism Industry Association of Colorado already registered in opposition to SB 135. HB 1297 has not official registered opposition and is scheduled for a vote in House committee next week. Rumor has it a compromise is in the works: the House bill will be amended to say that once Congress adopts a national law and at least four other adjacent states adopt the standard, Colorado would go forward.
· Ballot initiatives. Today is the final deadline for ballot initiatives to be proposed for the November 2022 election. Next week will briefly summarize what issues are in play and what decisions voters are likely to consider.
· COVID 19. Cases saw a slight uptick across the State this past week, but remain near the lowest levels detected since the pandemic began in 2020. We have had many recent inquiries about how the legislature is operating. We can safely say that the answer is captured best by “Pandemic? What Pandemic?” – with the exception of widely-used remote participation by both members and the public, nearly everything at the Capitol has returned to normal. Signs in the Capitol urge the use of masks, but only a very few people are seen wearing them on any given day. Although in smaller numbers, hosted receptions and events have also returned to the Capitol.
With the redistricting finalized, legislators and politicos are looking toward the 2022 legislative session which begins on January 12th. Here is a glimpse at some of the legislative proposals expected that will be of interest to CSOM.
- Scope of practice expansions top the list with the PAs seeking independent practice, optometrists pursuing the ability to perform laser surgery and multiple groups seeking the authority to initiate and release M-1 Holds. Also included in that M-1 Hold legislative proposal, emergency departments may be called upon to act as 72-hour hold facilities.
- The mandatory reporting statute will be opened up for amendments. There has been some confusion about reporters within an institution as to whom should do the reporting. Currently being contemplated is clarification that the professional is responsible for filing the report as well as requiring that physicians are responsible for reporting suspected abuse or neglect both within and outside of their professional setting. There may also be mandated continuing medical education added to the physician licensing requirements.
- There is expected to be a heavy progressive agenda in 2022. Part of that agenda includes the Colorado Trial Lawyers who are rumored to be pursuing legislation which would increase non-economic damage caps as well as attempting to remove the prohibition on the corporate practice of medicine.
- The Rural Health Preceptor tax credit program is up for renewal next year. There will be legislation to continue that tax credit.
- An attempt will be made to create a Gold Card recognition program for physicians which will streamline the prior-authorizations process.
- With the high numbers of teenaged vaping in Colorado, we expect a flavor ban (including menthol) on all tobacco products and limitations on the locations that may sell such products.
- On the topic of medical education are two noteworthy proposals. First, an alternate pathway to licensure for international medical graduates (IMGs) which may be in the form of ear-marked residency programs or a state funded office to assist IMGs with navigating the Colorado licensing system. Second, and probably of the most interesting is that the University of Northern Colorado will pursue the statutory authority to establish a new osteopathic medical school on the Greeley campus.
- Additional issues in the works include reimbursement for sepsis related care with clarifications around Sepsis 1 and 2 definitions, possible down-coding prohibitions and PDMP expansions.
Intense negotiation continue on HB 1232 – the Colorado (Public) Option. As of today physicians remain in the bill. Participation in the Colorado Potion Health Plan will be mandatory in areas necessary to achieve network adequacy. Reimbursement is set at 135% of Medicare. This will impact the RVU clinic as well as physicians.
Busy 2021 Legislative session. 623 bills introduced and 502 passed. The pass rate 83%. Unprecedented.
The major themes of the session were
- reducing health care costs
- social justice
- gun control
- regulating the marijuana industryThe progressive agenda had a great deal of success passing legislation in the areas of
- social justice
- controlling health care costs
- and tax reformIn addition to working with the legislators on bills, the Governor’s office and his staff were highly active participants in all the major theme issues. Many negotiations were directly with the Governor’s office.Some 2021 highlights include
We were successful in passing:
- An expansion of telemedicine
- Timely credentialing
- PA Independent practice
- Trial Lawyers bill extending the timeline economic claims by minors may be brought; and
- Their respondent superior bill
- DORAs ability to enact emergency orders (without Governor’s declaration)Most importantly we were able to amend two key bills:
- Health Care Billing for medically indigent patients
- As drafted – attestation, now – qualify
- As drafted – 80% Medicaid, now – 100% of the greater of Medicare or Medicaid
- Public Option
- Most time-consuming bill I’ve ever worked
- Able to remove any enforcement or mandate that physicians participate
- Contained Fee settingWhile all of that was taking place at the legislature, we were also able to overturn DORAs attempt to overturn peer health confidentiality and now have a rule assuring such confidentiality. CPHP has once again been awarded the peer health assistance contract.So, what should you expect in the 2022 legislative session which begins in January.The short answer is “more of the same,” but that begs the question “what does more of the same look like?” The players will not change.
- Health Care Billing for medically indigent patients
- same governor
- same legislators
- and the same legislative leadershipAdditionally, there will be a focus on the same issues:More specific to us
- PA bill will be back
- attacks from our trial lawyer friends (not just medical malpractice caps any more). They cannotlet this opportunity pass.
- Rural health tax preceptor tax credit
- Further reducing health care cost – a lot of focus on hospital and pharmaceutical costs
- more and better mental and behavioral health services AND at lower costsLooking forward, we must take into account the redistricting that is currently underway.Redistricting occurs every ten years and is intended to adjust legislative districts based in the census. New maps for redistricting will be out later this year.The district maps often change the voter registration numbers in each district and can pit two incumbent legislators against each other as districts merge or give the opposing party an advantage.The maps will also dictate the legislative agenda. Typically, legislative agendas in an election year are the least volatile. Incumbent legislators do not like to take divisive votes when up for reelection.If it looks like the maps will advantage the republicans, as the current drafts does, we will see a more volatile session.The democratic majority will push a more aggressive agenda while they have control of all three chambers. 2022 is shaping up to be a tumultuous legislative session.