In recent years, the AAHPM Public Policy Committee has effectively advocated on behalf of the Academy regarding federal legislation and regulations that impact our members and the patients we serve. However, many critical public policy decisions occur at the state level. Because the Academy’s organizational structure and staff resources do not allow for robust advocacy within each state, the Public Policy Committee established a working group to begin to track some of the “hot” issues and to think about how to build an infrastructure that would better enable AAHPM to stay abreast of state policy developments and support AAHPM members so they might become advocates for sound policy within their own states. The following are examples of some topics the State Issues Working Group is watching.

Opioid Prescribing
In response to an increasing number of overdose deaths linked to prescription opioids, many states are regulating opioid prescribing for chronic non-cancer pain. Adding pressure at the state level, US Senator Charles Grassley (R-Iowa) recently sent a letter to the directors of Medicaid programs in 33 states and the District of Columbia demanding an explanation of how they intend to deal with very high-volume prescribers of opioids and psychotropic medications. Grassley serves as the Ranking Member of the Senate Finance Committee’s Subcommittee on Health, which has jurisdiction over healthcare issues, including Medicare and Medicaid.

States are considering or have already put in place regulations that mandate consultation with a pain specialist for patients receiving above a specified daily opioid dosage, require prescribers to compare patients against a prescription monitoring database before prescribing opioids, or link licensure for opioid prescribing to enrollment in a prescription monitoring program. Education mandates are also under consideration in a number of states, from simple documentation of added training in pain management for opioid prescribers to higher levels of training to qualify for exemptions from mandatory referral requirements.

Members of AAHPM’s Public Policy Committee and the State Issues Working Group are sharing information regarding the content, development, and implementation of these regulations in an effort to ensure that patients receiving palliative care or hospice services have adequate access to opioid analgesics as well as to clinicians with appropriate training and skills in pain management. At the same time, we’ve looked for opportunities to offer the Academy as a resource and provide support as policy makers craft initiatives designed to prevent the diversion and misuse of prescription medications, to ensure the unique needs of our patient population are accounted for, and, hopefully, to avoid unintended consequences.

Health Insurance Reform
In December 2011, the US Department of Health and Human Services (HHS) issued a bulletin to provide guidance to states as they develop healthcare insurance exchanges required under the Affordable Care Act. The bulletin, provided in advance of a formal rule, addressed the “essential benefits” that plans offered through the exchanges must include and signaled that states will have the flexibility to base their packages on existing benchmark plans rather than federal standards. Although the guidance provided 10 categories of services deemed essential, hospice and palliative care were not included. AAHPM joined with its partners in the National Coalition for Hospice and Palliative Care in submitting a comment letter to HHS that makes a case for why they should be and urges the HHS Secretary to ensure hospice and palliative care services are included in all future guidance and rulemaking around essential health benefits. But, absent federal standards, working state by state to ensure that hospice and palliative care services are well integrated within benefits packages and new payment mechanisms will be a formidable challenge.

In addition to the State Issues Working Group, the Public Policy Committee has a working group examining emerging payment and delivery models. Its charge is to consider how to integrate hospice and palliative medicine within patient-centered medical homes, accountable care organizations, or any other delivery system that might evolve from healthcare reform efforts. Monitoring and responding to various state-level pilot programs will be crucial to ensure the field is well represented in the development of the healthcare systems of the future.

Advance Care Planning
State laws vary substantially regarding advance care planning, and issues arising in various states are correspondingly diverse. Proposed legislation or regulations that have been brought to our attention include standardized implementation of electronic advance directive registries, amending licensure laws to authorize mid-level practitioners to sign out-of-facility code status forms (eg, Physician Orders for Life-Sustaining Treatment [POLST]/ Medical Orders for Life-Sustaining Treatment [MOLST]), and granting immunity to providers who honor a POLST/ MOLST form stipulating do not resuscitate/do not attempt resuscitation/allow natural death. As multistate hospital systems adopt standardized systemwide electronic health records, scope of practice variation among states creates greater complexity.

Next Steps
We know the old adage “there’s strength in numbers” is particularly applicable when it comes to advocacy. It is important for the Academy to weigh in on issues, yet AAHPM’s leaders know the voice of hospice and palliative medicine is amplified if the organization works in coalitions. Toward that end, the State Issues Working Group is exploring liaison relationships with leaders of state hospice and palliative care organizations. However, for the Academy to be successful in meeting its public policy goals, we must all play a role. Given the critical issues being decided in Washington, DC, and state capitals across the nation, we can no longer afford to not consider advocacy as part of our job description.

Next on the agenda is building a grassroots network that can be mobilized to respond to calls to action—at both the state and federal levels—and increasing the resources available to Academy members so they have the information, training, and tools required to be effective advocates for their patients and the field. Identifying individuals to serve as “key contacts” in their states will also be critical, and we’ll look for ways to connect these members so they can benefit from lessons learned by colleagues who have taken on similar issues elsewhere. To make this project succeed, however, we need your input. What issues are developing in your state? What advocacy experiences can you share that will help others as they promote hospice and palliative medicine within their states? Are there health policy issues about which you would like to solicit input from AAHPM members with relevant expertise or experience? Are you interested in serving on the Public Policy Committee or one of its working groups? Let us know by e-mailing advocacy@aahpm.org