2018 Final General Assembly Report

This was a unique cycle in Virginia politics. A Democratic wave in the November 2017 elections reduced the Republican majority in the House of Delegates from 66 to 51 seats after a rollercoaster ride of close district elections, ballot recounts, and a tiebreaker that kept Republican control of the House by two seats. Coupled with the election of a new Governor and Lieutenant Governor (and the reelection of the incumbent Attorney General), we were in a holding pattern as we awaited election results that would determine which party controlled the House, and with it the Speakership, committee chairmanships, committee assignments, and the overall dynamic with the executive branch. As a result, the lead-up to and start of session on January 10 was anything but typical.

After the House Republicans retained power by a literal draw, Del. Kirk Cox (R-Colonial Heights) was unanimously elected as Speaker and rules were adopted keeping proportional representation on the committees. All committee meetings are now being live streamed, and subcommittee votes on legislation are recorded.

March 10, 2018 was Sine Die, the last day of this year’s General Assembly regular session, but legislators finished without producing a final budget. The two chambers are at an impasse over the expansion of Medicaid and how to spend- or cut- $600M. The House, in collaboration with Governor Northam, passed included Medicaid expansion in their version while the Senate did not.

Governor Northam called a special session to focus solely on the budget of the General Assembly, which convened on April 11th. Procedurally, the Governor sent down a budget bill that is virtually identical to Governor McAuliffe’s introduced budget. The House Appropriations committee convened on Friday, April 13thto take up the Governor’s budget, adopted their House version of the bill, but with two changes- cancelling the state employee pay raise and putting that money into the Revenue Stabilization Fund per comments from the bond rating agencies that said we were in danger of being downgraded if we didn’t have more savings. The full House then held a floor discussion on the budget on April 17th, sending their budget to the Senate for their consideration.  The Senate did not meet, dragging out the process further and finally saying they would reconvene on Monday, May 14th.  None of the conferees have been meeting, but there has been movement reported in the press with Senator Wagner signaling that he would be willing to vote for Medicaid expansion if certain conditions are met. That would give the pro- Medicaid expansion Senators enough votes to pass a budget containing those components.

Once a compromise is reached, the General Assembly will return and pass the budget that will then be sent to Governor Northam. At this point the Governor will have the ability to offer amendments. Upon the completion of the Governor’s review and any amendments, the General Assembly will reconvene to act on the Governor’s recommendations and send a final budget to him for his signature, all before June 30, 2018.

On April 18, the General Assembly reconvened to act on the Governor’s amendments and vetoes on the bills from the regular session. None of the bills we were following were taken up and it was a fairly routine day with all the vetoes being sustained because the Republicans do not have enough votes to overturn Governor Northam’s vetoes.

Healthcare continued to be a focus for the legislature, with the discussion focusing mainly on whether Medicaid would be expanded or not.  VACEP, along with our family physician and pediatric colleagues, sent a joint letter to the budget conferees and the Administration voicing our support for expansion and requesting them to consider additional reforms as part of the implementation process.

We continue to monitor the budget process, which is where the entire Medicaid expansion conversation has occurred and will be decided before the end of the fiscal year.

Since 2016 the physician community has been actively involved in efforts to engage the General Assembly in dialogue which would result in the passage of a thoughtful, statewide phase-out of the COPN regulatory process. Following the 2017 General Assembly Session and much discussion with senior members of the House of Delegates and Senate, the physician specialties involved decided to try a different approach and introduce individual project exemption legislation.

Twenty-five individual COPN exemption bills were introduced during the 2018 General Assembly Session Most of the bills died, but one bill calling for statewide repeal of COPN was carried over to the 2019 Session.  House Health, Welfare and Institutions Committee Chairman Bobby Orrock announced that he will convene a workgroup starting this April to study COPN during the off-session.

Nurse Practitioner ‘Transition to Practice’ (HB 793- Robinson)

Virginia passed the most stringent nurse practitioner “transition to practice” model in the country, requiring not only five years of post-graduate training for NPs, but also that the training be with a physician in the same specialty. Gov. Ralph Northam signed House Bill 793 into law in early April. The effort to create a transition to practice model for NP practice is thanks to the political advocacy efforts of the physician community, VACEP, MSV, and other specialty groups. Read more about VACEP’s efforts with the NP bill here.

Mental Health Treatment Admission Regulations

We strongly supported HB 886 (Stolle), a bill designed to help further alleviate any toxicology disagreements that may exist between an emergency physician and a psychiatrist at a mental health facility. It allows for the referring physician, often an EM physician, to ask the Poison Control Center to review the results of the toxicology screen and determine whether a medical reason for refusing admission to a psychiatric unit is related to the results of the toxicology screen. This is often already the practice, but it will now be in the law as a mechanism to solve a professional disagreement.  

Credentialing Reimbursement

Delegate Chris Head introduced HB 139, which will require insurance companies to reimburse physicians during a credentialing application period. Reimbursement will occur retroactively upon completion of credentialing. MSV estimates that, on average, this has the potential to avoid lost revenue of $100,000 – $150,000 per physician over a 90-day period. The bill passed both houses and was signed into law by the Governor.

Banning Balance Billing

Before session, we had struck an agreement with our fellow physician specialists and the VA Association of Health Plans that we would not put any bills in on AOB if they didn’t put any in to ban balance billing and instead we’d work in the summer of 2018 to craft a compromise. Two bills were still introduced by legislators, requested by constituents- an anti-balance billing study (SJ57-Sturtevant) and HB1584 (Byron), a bill to prohibit an out-of-network provider from charging an insured patient an amount for ancillary services that is greater than the allowed amount the carrier is obligated to pay to the covered person.  Both bills have been killed for the year, but HB 1584 was referred to the Health Insurance Reform Commission to be looked at this summer.

Doctorate of Medical Science

We opposed SB505  (Carrico) that created a new license for physician assistants who completed a newly created doctorate program at a university in Tennessee. It met with a lot of opposition from the physicians and physician assistant because this brand-new degree is untested and not yet accredited. The first class just started in the Fall of 2016 and we believe it is far too early for Virginia to grant a new license for such a nascent profession.  The bill was continued until 2019, killing it for the year.

Air Ambulance Informed Consent                                                                  

We closely followed two bills this session that attempted to address the complex issue of air ambulance services, particularly when the air transport is out of network.  One bill would have required informed consent at the scene of the incident BEFORE calling the air medical transport. The EMS community strongly opposed the bill and even after many amendments, could not come to an agreement on the bill and it was killed for the year (HB777 – Ransone). The second bill, HB 778 (Ransone) we worked closely on with the Virginia Hospital and Healthcare Association to ensure that emergency situations were NOT included. We were successful and the final bill requires hospitals to establish protocols for written notice of air transport for non-emergency medical conditions.