State Rep. David Knight had a triumphant look Friday when talking about his quest for more oversight and restrictions on the PBM industry.
Pharmacy Benefit Managers are basically corporate middlemen between health insurers or large employers and drugmakers in handling pharmaceutical benefits. The Georgia General Assembly approved a group of bills in recent days to rein in how PBMs operate.
“I think these bills probably are the most comprehensive PBM reform legislation in the nation,’’ said Knight, a Griffin Republican. He has arguably been the biggest legislative critic of these entities, and he led the push for the new measures.
The restrictions included closing current loopholes on laws prohibiting PBMs from steering patients to certain pharmacies. They create new oversight over government health care contractors, and provide more transparency on prescription pricing. “It’s a total change of the landscape in Georgia,’’ Knight told a reporter in his state Capitol office.
Through the activities of PBMs, patients can be pushed toward expensive brand-name drugs, rather than less costly generic drugs, he added. Under the new legislation, the state insurance commissioner would get more authority to regulate PBM practices.
Knight spoke to GHN on the PBM legislation on Sine Die, the 40th and final day of the 2020 legislative session.
The atmosphere at the Capitol in Atlanta on Friday was a vivid contrast to such concluding days in past General Assembly sessions.
The typical circus-like gathering of lobbyists, relatives of lawmaker and visitors clogging the halls gave way this year to mostly empty corridors.
The mostly solitary figures in the hallways wore protective masks, as did lawmakers lined up in rows to celebrate the signing of the newly passed hate crimes bill on the steps leading to the third floor.
COVID-19 fundamentally changed the logistics of the legislative session, causing a hiatus that stretched into months.
Yet over the last two weeks, after lawmakers finally reconvened, they produced several important bills involving health care, and a budget that had milder cuts to vital programs than had been feared.
Surprise billing stalemate finally ends
For at least five years, proposals to curb surprise medical billing have run into intractable deadlocks in the Legislature.
A deep divide existed between health insurers and physicians over how to fix the problem, and lawmakers tended to line up with one side or the other, resulting in no reforms being passed.
Not so this year.
House Bill 888, which passed both chambers, addresses surprise billing that occurs after elective surgery or emergency care, when the facility itself is in the patient’s insurance network but the ER physician, anesthesiologist, radiologist or pathologist is not. In such cases, the patient gets a separate, unexpected bill from that out-of-network doctor, a bill that can reach into the thousands of dollars.
“We’re going to finally take the consumer out of the middle of this issue and leave it between the health care provider and the insurer to resolve,” said Sen. Chuck Hufstetler (R-Rome), who has fought for years to ease the billing problem.
The legislation won’t apply to people covered by large, self-insured employers.
Still, consumer advocacy organization Georgia Watch praised the legislation action.
“After years of steadfast advocacy to protect consumers from surprise medical bills, we are grateful that Georgians will soon be taken out of the middle of these billing disputes,’’ said Berneta Haynes of Georgia Watch. “This is a huge victory for patients and will bring urgent relief to Georgians struggling under the weight of medical bills during the ongoing COVID-19 public health crisis.’’
Another bill, sponsored by Rep. Mark Newton (R-Augusta), who’s a physician, establishes a rating system that patients could use to determine which physician specialty groups in their insurer’s network serve a specific hospital.
Newton’s bill applies to anesthesiologists, pathologists, radiologists and emergency room physicians – doctors often responsible for the most cases of surprise billing.
Health and dollars
SENIOR CARE: Legislation to impose new oversight and staffing requirements on senior care facilities passed overwhelmingly. The issue was brought to lawmakers’ attention by a series of articles in the AJC. The House unanimously signed off on the Senate’s version of the bill, which added requirements for handling COVID-19 to the bill’s reforms of the senior care industry.
“I am so proud of Georgia’s House and Senate for making the necessary changes to ensure the safety of our seniors who choose to live in assisted living facilities,” said Rep. Sharon Cooper (R-Marietta), the lead sponsor of the bill.
MATERNAL MORTALITY: Georgia will get more financial resources to lower its high rate of maternal mortality. That’s defined as the death of a woman while she is pregnant or within one year after the end of her pregnancy, from any cause related to or aggravated by the pregnancy or its management.
House Bill 1114 authorizes the state to apply for a federal waiver that would allow Georgia to offer Medicaid coverage to eligible women up to six months after they give birth. The current Georgia Medicaid program permits coverage only up to two months.
“We are incredibly grateful to the [budget] conferees and Appropriations leadership for restoring the vast majority of the maternal mortality funding needed to address our state’s dire maternal health crisis,’’ said Elise Blasingame of the Healthy Mothers, Healthy Babies Coalition of Georgia. “This is a huge step in the right direction and will benefit thousands of mothers who currently do not have adequate access to critical care in the postpartum period.’’
LIABILITY PROTECTION: The General Assembly passed legislation aimed at shielding businesses and health care providers from lawsuits filed by people who have contracted coronavirus since March.
The bill would shield companies from legal liability unless they show “gross negligence, willful and wanton misconduct, reckless infliction of harm, or intentional infliction of harm.”
The measure cleared the Georgia Senate on a largely party-line vote of 34-16 during the final minutes of the 2020 legislative session, sending it to Gov. Brian Kemp for his signature.
Democrats criticized the liability protections being afforded to senior care facilities, whose practices faced intense scrutiny in Georgia even before the pandemic struck, the AJC reported.
ETHYLENE OXIDE The General Assembly passed a bill to require medical sterilizing companies to report any unpermitted release or leak of the toxic gas ethylene oxide to state regulators, who then would be required to disclose it to the public.
Releases of the cancer-causing ethylene oxide from sterilizing facilities have triggered community protests in two areas of metro Atlanta in recent months. Last year, a report by WebMD and Georgia Health News identified three metro Atlanta census tracts in EPA data as having an elevated cancer risks from air pollution, largely due to ethylene oxide. Two of the tracts are in Fulton County, near a medical sterilization facility run by the company Sterigenics. The third is in Covington in Newton County, where the company BD operates a sterilizing plant.
Jason McCarthy, a leader of an activist group based in Covington that opposes use of ethylene oxide, called passage of the legislation a big victory.
“Transparency is arguably the only weapon the citizens can leverage,’’ McCarthy told GHN. “We can now monitor spills which has long been an unknown, but important, variable.’’ McCarthy thanked Sen. Brian Strickland (R-McDonough) and Rep. Erick Allen (D-Smyrna), “for not letting this die amidst the COVID noise. That would have been easy for them to do.’’
COAL ASH: State lawmakers passed Senate Bill 123, which would raise the fee for storing coal ash in landfills from $1 per ton to $2.50 per ton — the amount charged for other forms of household waste. Previously, Georgia’s low coal ash disposal fee had been an incentive for out-of-state utilities to transport the waste here.
Local officials will soon be required to spend 20 percent of the fees on environmental and educational efforts. Several other coal ash bills, including one to force utilities to move such waste into lined landfills, died earlier in the legislative session.
TOBACCO TAX: Legislation to raise the tobacco tax failed to gather momentum in the closing days of the legislative session.
Health care organizations, including four physician groups, pushed the longtime idea of raising the state tobacco tax. Georgia’s levy, at 37 cents a pack, trails only those in Missouri and Virginia.
Raising the tobacco tax to the national average, $1.81, and taxing vaping products would raise up to $600 million per year annually, according to an estimate by the Georgia Budget and Policy Institute, a think tank. That move would erase pending cuts across the major health agencies, said Laura Harker of GPBI.
But the effort to hike the tobacco tax didn’t get off the ground, presumably because of opposition from House Speaker David Ralston (R-Blue Ridge) and Gov. Brian Kemp.
The Legislature, though, did vote to impose a tax of up to 7 percent on vaping products and raise the age to buy both the nicotine delivery devices and tobacco to 21 from 18. The new tax could bring in as much as $19 million, according to the bill’s sponsor.
Budget picture a bit less gloomy
The COVID-19 pandemic, which caused state revenues to plummet, led to plans for drastic budget cuts. But some of the pain was eased in late-week negotiations between House and Senate leaders.
Legislative budget writers drew $250 million from the state’s general fund reserves and $50 million from Georgia’s share of the national tobacco settlement to help offset some of the impact of the cuts, according to the Capitol Beat News Service.
As a result, the budget will reduce state spending across the board by 10 percent instead of the 14 percent originally outlined by Gov. Kemp.
Still, the conferees were forced to make difficult decisions, said Rep. Terry England (R-Auburn), chairman of the House Appropriations Committee.
“There was no option but to have to make some of these cuts,” said England. “They were not done out of malice but out of necessity.”
The new blueprint eliminates the plan for furlough days for state employees, including health workers. It also erases the proposed $14 million cut in grants to local Public Health departments.
Cuts to autism programs have been reduced. Morehouse and Mercer medical schools won’t face the steep reductions in state funding that were outlined in previous budgets.
Mental health and substance abuse programs generally will see significant cuts, but not as deep as those previously planned.
The Georgia Mental Health Consumer Network said it faces less serious cuts than were outlined during the week. The group runs five wellness and recovery centers for people with mental illness.
“We’re going to do our best to keep all five of them open,’’ said Sherry Jenkins Tucker of the organization, though funding from the state will be reduced by $1 million. “This is about all the people who depend on us every day to support them with recovery and wellness.’’
The Georgia Council on Developmental Disabilities praised the budget’s inclusion of more waivers that provide home and community-based services for people with disabilities.
The council, though, also said it “remains concerned about the deep cuts to services and supports for Georgians with developmental disabilities. We know people with developmental disabilities live in communities all across the state, and the safety net that public services provide makes all these communities more secure.’’
Polly McKinney of the group Voices for Georgia’s Children said lawmakers made “a few really smart and strategic additions’’ to the budget that will make a significant difference. She named the Medicaid coverage extension, a school-based health center in Irwin County, and the DFCS Afterschool Care Program, among others.
“All these things work together to keep children healthy both physically and mentally,’’ she said.
Max Blau contributed to this article.