Over the past four months, lawmakers in Helena have debated and fine-tuned a slate of policies designed to address Montana’s long-standing issues with medical access and affordability. Several of those bills are now poised to take effect, a development that health care leaders hail as welcome progress following a year of immense challenge.
One major change rises directly from the nation’s response to the COVID-19 pandemic, specifically the temporary lifting of regulations governing telehealth services. A pair of bills passed by the Legislature make those regulatory suspensions permanent while expanding telehealth’s prospective post-pandemic role in Montana. Senate Bill 347 allows patients to receive remote treatment not just from physicians and mental health professionals but from physical therapists, speech pathologists and audiologists. It also ensures that telehealth is covered under Medicaid and, in a nod to rural areas lacking in reliable internet, extends to audio-only communications. SB 347, which was sponsored by Sen. Jen Gross, D-Billings, is currently awaiting Gov. Greg Gianforte’s signature.
The other key piece of telehealth legislation, House Bill 43, establishes in state law that telehealth services must be covered by health insurance plans and sets up clear definitions for what constitutes telehealth. That bill, sponsored by Rep. Rhonda Knudsen, R-Culbertson, has been signed into law. Both measures were approved with strong bipartisan support and won the backing of health care advocates and Montana Insurance Commissioner Troy Downing.
Telehealth is booming. But with the boom come unintended consequences, including conflicts between out-of-state and in-state health providers, a rise in fraud, and potential access problems for vulnerable groups.
Rich Rasmussen, president of the Montana Hospital Association, said the new policies are an important and logical progression for a state with a long history of utilizing telehealth options. In addition to rural residents and patients with mobility challenges, Medicaid enrollees in Montana’s workforce stand to benefit considerably from the changes. Rasmussen said telehealth opens the possibility for employees to get necessary health care without having to leave work or carve time out of cramped schedules to visit a clinic in person. MHA Vice President Heather O’Hara likened it to the telehealth counseling her daughter has received during the pandemic.
“She actually doesn’t have to leave school now to go and talk to a counselor. She goes to a room at the school and is able to do telehealth right there in school,” O’Hara said. “So she’s not missing as much school and I’m not having to drive across town, pick her up and take her to her counseling session, so I’m not missing work.”
The pandemic-induced suspension of telehealth regulations has already hinted at untapped demand among Medicaid enrollees. According to a report released in February by the Montana Healthcare Foundation, telehealth visits for physical health issues among those who qualify for Medicaid increased 100% last year, while visits for behavioral health issues increased 1,400%.
The duty of policing those coverage promises for telehealth will fall to Downing, who told Montana Free Press he doesn’t anticipate any problems. Insurance providers in the state have already adopted and embraced the temporary orders handed down by the federal government and former Gov. Steve Bullock, he said. Downing added that his office will respond to and investigate any complaints, as it does with all consumer reports of noncompliance.
Another legal change Montana physicians and patients are likely to note is an expanded role for medical practitioners in dispensing prescription drugs. Prior to the Legislature’s passage of Senate Bill 374, doctors could give drugs directly to patients only in limited circumstances. SB 374, which is now awaiting Gianforte’s signature, would give practitioners the ability to dispense drugs that are within their scope of practice with the exception of controlled substances. Those practitioners would first be required to register with the Montana Board of Pharmacy.
Jean Branscum, CEO of the Montana Medical Association, said SB 374 will make for more comprehensive and effective clinical visits, particularly in situations where the addition of an extra trip to a pharmacist poses a significant barrier to care. She added that it will also allow some practitioners, such as dermatologists, more flexibility in trying potential treatments without committing to seven- or 14-day regimes, and will facilitate better adherence to proper medication usage overall.
“This allows for that one-on-one discussion with the physician on how important it is to take the medication, don’t over-take that medication,” Branscum said. “People might have additional symptoms so they take that second pill. They should know not to do that. That education right there with the physician is important, so patient safety is improved.”
Downing noted that another proposed policy change, Senate Bill 395, is poised to help drive down the costs of those drugs in Montana. SB 395 passed the Legislature with little opposition, and if signed into law will give Downing’s office the authority to regulate pharmacy benefit managers — the so-called middlemen of the prescription drug world. Downing said SB 395, by requiring those managers to register with his office and report the money they receive from drug manufacturers, will bring greater transparency to what’s driving drug costs in the state. A similar law in Arkansas was upheld by the U.S. Supreme Court last December.
“Prescription drugs are the fastest-growing expense in patient care costs,” Downing said. “So we think that this is going to be meaningful.”
DIRECT PRIMARY CARE
For Todd Bergland, a family physician at Fountainhead Family Med in Whitefish, one new law in particular has given stability to a style of medical practice he embarked on a year and a half ago. Senate Bill 101 sets into state statute a memo issued in December 2017 by Downing’s predecessor, Matt Rosendale, authorizing doctors to negotiate direct payments from their patients. Those “direct primary care” agreements cover an established suite of health care services, and eight clinics in Montana now operate with that model. Under SB 101, as in Rosendale’s memo, they are not considered health insurance and as such are not regulated by the state.
Sen. Cary Smith, R-Billings, introduced Senate Bill 101 to members of the Senate Business, Labor and Economic Affairs Committee, stating that the legislation would help strengthen relationships between health care providers and their patients and give Montanans access to another option for affordable health care.
Branscum believes the codification of that memo will lead to more physicians making such agreements a part of their practice. Bergland, who also serves as president of the Montana Direct Primary Care Association, agrees, saying the security of the new law makes the situation “less scary” for providers and will result in better access and more affordable health care options for patients. For an adult under the age of 60, Bergland said, membership at his clinic costs $70 a month and covers a long list of primary services. He also argues that the model fosters better relationships between providers and patients than the existing insurance-dominated system.
“It doesn’t have to be seven-minute visits and it doesn’t have to be insanely overpriced testing and it doesn’t have to be just loads of insurance company paperwork that doesn’t benefit the patient at all,” Bergland said. “There’s a better way to do it.”
The new law does set some rules around direct primary care, including that a warning be attached to all DPC agreements noting that they are not health insurance. Downing and others view the agreements not as a replacement for health insurance, but rather a supplement to higher-deductible plans that cover catastrophic situations. SB 101 also expands the model from primary care to patient care in general, allowing other health care providers such as dentists and dermatologists to utilize direct care agreements as well.
Rasmussen is particularly interested to see if the potential “fast-track” to primary care for patients under DPCs will be offset by Montana’s embrace of telehealth, as both measures are aimed at improving access to care.
“A little over a year ago, we had a number of regulatory impediments that stopped the broad adoption and use of telehealth,” Rasmussen said. “We don’t have those anymore. And I think one of the advantages that came from stripping away some of this needless regulation over telehealth is it allowed patients to be able to access their physician much more quickly than they had in the past. So the jury will be out on how [DPCs] will grow. But again, if it allows for people to have greater access to their primary care physician, that’s a good thing because that helps manage care better.”