South Carolina Hospital Association Newsletter


	Inside this issue

	• A Wrap on the 2019 Legislative Session • 2019-2020 Budget Items • Scope of Practice for Physician Assistants • Physician Order for Scope of Treatment (POST) • Clinical Preceptor Tax Credits • Adult Health Care Consent Act • Opioid Antidote Reporting and Electronic Prescription Mandate • Addressing the Accumulated Deficit of the JUA and PCF

	A Wrap on the 2019 Legislative Session
	The General Assembly returned for two days this week to tie up loose ends and submit their budget to the Governor. The legislature indicated they do not plan to return until January, barring unforeseen circumstances. While in Columbia, they also approved conference committee reports for a few bills, including the Adult Health Care Consent Act and POST. Some items did not make it across the finish line this year and, in many cases, we welcome the delay. Outstanding items will pick up where they left off when the legislature returns in January. Priority items for SCHA will carry over and we will continue our work on workplace safety and joining the Interstate Medical Licensure Compact next year, in addition to several new items of interest. SCHA successfully fought on behalf of hospitals in a variety of areas this year. There are several important items to be aware of that have or will become law after passing this year, and details of those are included in this newsletter. Unless special circumstances arise and the legislature returns earlier than expected, this will be the last edition of The Pulse for 2019. Please feel free to reach out to Krista Hinson, Director of Government Relations at SCHA, with any advocacy-related questions throughout the year. She can be reached at khinson@scha.org.
	Top

	2019-2020 Budget Items
	H. 4000 The budget for the upcoming state fiscal year includes two very important items for SCHA and healthcare in South Carolina. Proviso 33.15 requires the South Carolina Department of Health and Human Services (DHHS) to submit a waiver to CMS to ensure that our state's Children's Health Insurance Program (CHIP) income limit is at least as high as the southeastern average. South Carolina's CHIP income limits are the lowest in the region and among the lowest in the country. This proviso will increase the limits by at least twenty-five points, as a percent of the federal poverty level. Proviso 117.126 adds language that requires DHHS and the Public Employee Benefit Authority to submit a report outlining how they intend to broaden their service-based coverage for telehealth services. This proviso recognizes changes in federal law that may allow for updates to the state reimbursement policies to improve the sustainability of telemedicine. The budget will be effective July 1, 2019 through June 30, 2020.
	Top

	Scope of Practice for Physician Assistants
	S. 132 by Senator Davis Similar to a bill passed last year expanding the scope of practice for advanced practice registered nurses, this bill expands the scope of practice for physician assistants. Details of the expanded practice include: Prescriptive authority for Schedule III-V drugs and Schedule II non-narcotic drugs Prescriptive authority to write up to a five-day supply of Schedule II narcotic drugs Eliminates the previous 60-mile radius requirement, replacing it with the state borders Eliminates the requirement for 10% of off-site charts to be reviewed and signed by the supervising physician, allowing the physician to determine the appropriate review guidelines at an individual practice level Increases the physician to PA ratio from 1:3 to 1:6 full time equivalent mid-level providers per physician Allows PAs to sign death certificates and handicap placards, as well
	Top

	Physician Order for Scope of Treatment (POST)
	H. 4004 by Representative Clary The South Carolina Coalition for the Care of the Seriously Ill (SC CSI) has worked for years on developing language for an end-of-life care medical order law, known as a physician order for scope of treatment (POST). The POST legislation was developed in collaboration with the Elder Law committee of the SC Bar Association prior to introduction but faced scrutiny from the pro-life community during the committee process. Additional language was added to the bill explaining the intention and explicitly stating that it is not intended to be used as a means to physician-assisted suicide and that it is entirely optional for any patient. Final language allows physicians, nurse practitioners, and physicians assistants to execute a POST form outlining a patient's wishes for treatment in the end of their life. The form will be created by DHEC and made available for healthcare providers throughout the state. It is intended to be a transferable document that a patient can take with them from hospital to hospital if traveling during the last year of their life.
	Top

Clinical Preceptor Tax Credits

S. 314 by Senator Alexander
This bill establishes an income tax credit for physicians, advanced practice registered nurses, and physician assistants who serve as a preceptor for rotations required as part of student clinical training experiences. The credit amount is based on the percentage of the preceptor's practice that is Medicaid, Medicare, and self-pay patients combined. No more than four credits may be claimed by a preceptor per year.

For physicians serving as preceptors, the credit per rotation, up to four, is:

$1,000, for physicians with at least 50% Medicaid, Medicare, and self-pay patients
$750, for physicians with 30-50% Medicaid, Medicare, and self-pay patients
Disallowed for physicians with less than 30% Medicaid, Medicare, and self-pay patients

For APRNs and PAs serving as preceptors, the credit per rotation, up to four, is:

$750, for preceptors with at least 50% Medicaid, Medicare, and self-pay patients
$500, for preceptors with 30-50% Medicaid, Medicare, and self-pay patients
Disallowed for preceptors with less than 30% Medicaid, Medicare, and self-pay patients

The tax credit is phased-in in equal installments over a period of five years. A tax deduction was created during the phase-in period. Preceptors will be able to deduct from their income tax total the amount of the full credit that has not been phased-in yet in a given year. By 2026, the full tax credit will be available and the deduction with be repealed.

Top

	Adult Health Care Consent Act
	H. 3602 by Representative Rose Healthcare facilities are increasingly faced with patients who have no family members to make decisions on a patient's behalf. In this case, a guardian must be appointed by the probate court to consent to proceeding with medical treatment. Attorneys familiar with the guardian appointment process testified that it often takes as long as 45 days for a non-emergency guardian to be appointed. In that time, the patient is going without treatment and using valuable hospital resources while they wait. According to testimony heard in subcommittee meetings, 37 states have enacted 'close friend' provisions to add an option for individuals without family or advance directives available. A bill to add a provision to a close friend provision to the end of South Carolina's Adult Health Care Consent Act allowing a close friend to make healthcare decisions for a patient unable to consent passed the legislature this year. The legislation was amended during the committee process to prohibit a paid caregiver to make healthcare decisions for a patient under this provision. The bill also requires the close friend to sign a notarized form attesting to the nature of their relationship with the patient. Last-minute amendments moved the existing priority ranking number three, related to individuals given authority to make decisions by another statute in the code, down below family members. The close friend provision will follow those given authority by another statute at the end of the ranking list.
	Top

Opioid Antidote Reporting and Electronic Prescription Mandate

H. 3728 by Representative Fry

This bill by the House Opioid Abuse Prevention Study Subcommittee requires the reporting of opioid antidote administration in a healthcare facility and by EMS when there has been a diagnosed overdose. The premise of the bill is to provide this information in the prescription drug monitoring program to provide a thorough picture of a patient's history with prescription drugs and drug misuse.

Hospitals and health systems will be required to report the antidote administration electronically or by fax to DHEC within thirty days after discharge. The following information must be sent to DHEC's Bureau of Drug Control when a patient receives an opioid antidote and has a diagnosis indicating an opioid overdose:

date of administration of opioid antidote
name, address, and date of birth of the person to whom the opioid antidote was administered

Additional language added to the bill requires practitioners to use electronic prescriptions for Schedule II through Schedule V drugs. Exceptions to this requirement include:

a practitioner, other than a pharmacist, who dispenses directly to the user
a practitioner ordering a prescription for administration in a hospital, nursing home, hospice facility, outpatient dialysis facility, or residential care facility
a practitioner who experiences temporary technological or electrical failure or other extenuating technical circumstances that prevent a prescription from being transmitted electronically; however, the practitioner must document the reason for this exception in the patient's medical record
a practitioner who writes a prescription for a controlled substance included in Schedules II through V to be dispensed by a pharmacy located on federal property; however, the practitioner must document the reason for this exception in the patient's medical record
a person licensed to practice veterinary medicine pursuant to Chapter 69, Title 40
a practitioner who writes a prescription for a controlled substance included in Schedules II through V for a patient who is being discharged from a hospital, emergency department, or urgent care.

This language is very similar to federal legislation passed last year requiring the use of electronic prescriptions for providers accepting Medicare.

Top

	Addressing the Accumulated Deficit of the JUA and PCF
	H. 3760 by Representative Sandifer The Joint Underwriters Association (JUA) and Patient's Compensation Fund (PCF) accumulated nearly $200,000,000 in combined deficits a few decades ago. Since that time, each entity has done work to reduce their deficit but, according to the Department of Insurance, has hit a plateau in their ability to pay off the remaining deficits. As of March 2019, the combined deficit is around $86,000,000. This bill addresses the accumulated deficit and aims to prevent future deficits from forming by merging the JUA and PCF into one new entity and changing the intended operation of that entity, the South Carolina Medical Malpractice Association (SCMMA). To pay off the existing accumulated deficits, the SCMMA must assess the members of the association between two and six percent of total written premiums. Members of the association include insurance carriers writing medical malpractice and other healthcare professional liability coverage. The insurance carriers must pass one percent of the assessment on to their policyholders and can absorb or pass on the remaining amount at their own discretion. A broker charge of the same percentage will be charged to surplus lines insurance. Additionally, insurance carriers not writing medical malpractice insurance are able to buy-out of the association by applying for and paying a withdrawal fee in order to avoid future assessments. The money collected from withdrawal fees will be applied to the accumulated deficit. The assessments may begin in 2020 and will continue until the deficits are eliminated or December 31, 2035, whichever is sooner. Healthcare providers covered through the SCMMA will have an additional one percent surcharge added to their premium each year for ten years, until there is a ten-point differential between the SCMMA rates and the competitive private market rates. The differential will remain indefinitely to separate the SCMMA from the private market and move it to the market of last resort, as intended. The SCMMA will be controlled by a Board consisting of four providers, recommended by the SC Hospital Association, Medical Association, Nursing Association, and Dental Association; four medical malpractice insurance carrier representatives; two consumers; and one independent agent. The Director of the Department of Insurance will serve as ex-officio, non-voting member and will act as chair of the Board for SCMMA.
	Top

May 23, 2019