More than 25 years ago, federal lawmakers wisely saw fit to enact the so-called "Stark laws," limiting physician referrals to facilities in which they have a financial interest and preventing health care providers from acting in their own financial self-interest, rather than in the best medical interest of their patients.

There are similar regulations in Maryland that nullify any financial motivation for further diagnostic testing, limit unnecessary utilization and, as a result, help keep health care costs in check. In fact, Maryland has some of the toughest laws in the country.

This system, which has served Marylanders well for years, is under direct attack in the General Assembly, with a well-funded push to loosen the regulations and allow medical oncologists to both own radiation therapy and CT services and refer patients to those services in which they have a direct financial interest.

To be blunt, this is an uphill battle for hospitals to fight - partially because supporters of the change are arguing their point on an emotional, rather than factual level. They are focusing on individual stories of cancer patients who testify about access problems, and they are claiming they are asking for only the narrowest of exceptions. Of course, with nearly four dozen hospitals statewide that offer radiation therapy services (not to mention a slew of other providers), the access concern is entirely a straw man argument.

But that doesn't mean it's not compelling for legislators unfamiliar with the issue.

We've been working to counter that sentiment with hard facts about how loosening these regulations actually generates suspect, unnecessary care. Numerous studies show that physician self-referral leads to increased utilization of services that may not be medically necessary, poses potential harm to patients and costs the health care system millions of dollars each year.

A few examples from recent reports from the federal Government Accountability Office:

• Medicare spent $109 million more in 2010 than it would have without self-referral incentives
• From 2004 to 2010, the number of self-referred MRI services increased by more than 80 percent, compared to a 12 percent increase for non-self-referred MRI services.
• Increased self-referrals in 2010 led to more than 900,000 unnecessary referrals

There was a hearing on this bill earlier this week and the testimony from our panel was both merit-based and powerful. While some legislators seem supportive of our position, nothing is certain until the votes are counted.

March 23 marks cross-over day when bills from each chamber with favorable votes make their way to the opposite chamber. MHA will aggressively monitor and move bills of importance through the process. Following is a snapshot of important issues from this week's action.

On Monday, MHA testified in strong opposition to HB683 Health Occupations-Magnetic Resonance Imaging Services and Computed Tomography Scan Services-Patient Referrals, which would provide an exception to the state's prohibition on physicians and other health care providers referring patients to facilities in which the provider has an ownership or financial interest. This bill is similar to HB944-SB539, but not limited to radiation therapy. MHA also testified in strong opposition to HB944-SB539 Patient Referrals-Oncologists Radiation Therapy Services and Nondiagnostic Computer Tomography Scan Services. This bill alters the definition of "in-office ancillary services" to include specified oncology group practices or offices of oncologists who provide specified radiation therapy services or computer tomography services, in order to exempt them from the state's prohibitions on self-referral. The ability of a provider to refer a patient to a facility owned in whole or in part by that provider has long been prohibited in both federal and state law, for good reason. Decisions about patient care should be made strictly in the best interests of the patient, not potentially sullied by that provider's potential financial gain.

Also on Monday, MHA, along with several panels, testified in support of SB585-HB553 Maryland No-Fault Injured Baby Fund, a critical measure to ensure that the tens of thousands of women who give birth in Maryland each year have access to quality obstetric services. In addition, for the handful of cases each year that would qualify for reimbursement from this fund, a no-fault mechanism provides timely, efficient compensation - without asking injured parties to play in the "litigation lottery," where results are uncertain and won't be determined for years. This bill was jointly assigned to both the House Judiciary and Health and Government Operations committees.

On Tuesday, MHA testified in opposition of HB1101-Department of Health and Mental Hygiene-Health Program Integrity and Recovery Activities, which would substantially amend current law governing hospital and other health care provider participation in the Medical Assistance Program ("Medicaid") by imposing a substantial risk of recoupment of paid claims not based on identified claims errors - those found not to be eligible for reimbursement - but instead to be based on an extrapolation. In addition, it would require the posting of a substantial bond for each "location" in which care is rendered, leading to the imposition of a substantial financial burden on hospitals and other health care providers simply to be eligible to provide services to Medicaid beneficiaries. Rather than encouraging and facilitating care to the indigent population eligible for Medicaid benefits, this legislation imposes excessive burdens on providers of care.

MHA provided supportive written and oral testimony on Tuesday for HB71-SB56 Creation of a State Debt-Maryland Consolidated Capital Bond Loan of 2015, which authorizes the creation of a state debt in the amount of $1.068 billion, the proceeds to be used for various capital projects. MHA's project requests are over $3.6 million to provide an array of expanded and enhanced services with a focus on improving patient safety, expanding access to care, and reducing unnecessary admissions and readmissions. Although the program is authorized to request up to $5 million, the fiscal year 2016 request falls slightly short of this limit. The changing and uncertain landscape of hospital financing under the new hospital Medicare waiver has resulted in a conservative request by hospitals to begin new capital projects. Moving forward, we expect that funding requests will be at the $5 million appropriation level and higher in 2019, 2020.   

On Thursday, MHA offered written testimony in opposition of HB969-SB688 Labor and Employment-Fair Scheduling Act, which requires an employer to provide employees with a specified work schedule within a specified time period, notify employees of specified changes, and provide employees with a new work schedule within 24 hours after making a change to the initial schedule; requiring an employer to conspicuously post at each work site specified work schedules; requiring an employer to pay specified predictability pay under specified circumstances. The very nature of hospital work dictates that hospital leaders must have flexibility in scheduling workers. Sickness, illness, accidents, and catastrophes do not occur on regular schedules. Requiring 21 days of notice for an employee's work schedule, as the bill does, and mandating that a worker begin his schedule on the same day of each week, is simply not tenable in the fast-paced and quickly-changing environment of hospital care.

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