07/01/2024

OPPA successfully brokers a deal on SB 60

As members are likely aware, OPPA originally took a position of active opposition to Senate Bill 60 – a bill that would create a new mid-level mental health profession - Certified Mental Health Assistant. There were significant concerns about the legislation, including training and education, lack of specificity, as well as patient and physician protections.

OPPA members, executive director, and contract lobbyist have worked tirelessly to oppose the bill since it was first introduced early last year. Through our effective advocacy, we were able to stop the bill from being voted out of the Senate Workforce and Higher Education committee on three separate occasions and successfully had the bill language removed from the state budget in 2023.

After months of expressing our opposition to the bill the chair and the sponsor came to us and indicated they would be willing to make significant changes to the bill to address the issues we highlighted, but also indicated continuing to stop the bill in its entirety was not possible. We were asked to identify our top ten major concerns with the bill and our potential solutions to those issues. We are happy to report we were successful in working with the chair, sponsor and committee members to include all 10 items that we requested, which is a huge win for psychiatrists and individuals with mental illness.

The OPPA, in partnership with OSMA, was successful in making the following changes:

• Added language requiring all CMHA educational programs follow ARC-PA accreditation standards.
• Added language established a committee within the medical board, made up of physicians who are appointed through recommendation from OSMA and OPPA, who will review all CMHA program curriculums before curriculums are sent to Ohio Department of Higher Ed for accreditation.
• Added language ensuring all CMHA programs are master’s level programs with a minimum of 30 credit hours.
• Added language ensuring all CMHA must have a 4 year under graduate degree before applying for a CMHA program.
• Reinstated specifics around 9 additional areas of course work to supplement the mental health education.
• Clarified that the scope of practice would be limited to that of the supervising physician and ensuring the serviced rendered by the CMHA are within the supervising physician’s regular area of practice and expertise.
• Removed language that would have given broad authority to the medical board to establish scope of practice expansions.
• Clarified provision is not necessary to ensure liability coverage of CMHA, the Ohio Department of Insurance confirmed a CMHA will be covered.
• Provision added that required reimbursement through Ohio’s Medicaid Program.
• Added an additional 500 hours under which a CMHA must be under direct supervision.
• Removed language that would have allowed a CMHA to pink slip a patient.
• Removed language that would have allowed a CMHA to refer a patient to a physical therapist or athletic trainer.
• Added language that requires the State Medical board to promulgate rules around additional quality assurance standards a CMHA will have to follow.

OPPA’s New Positions on the Bill

In exchange for making all the amendments requested, Leaders of OPPA chose to take a position of Interested Party. While we would have preferred to kill the bill, that simply wasn't going to happen due to numerous factors. Had we not engaged in an opportunity to make amendments, the bill would have passed out of committee with the language that was first introduced.

We believe the new position of interested party gives us the opportunity to continue educating lawmakers on this proposal, while acknowledging the strides the chair and sponsor made to address our main concerns with the legislation.

Last Wednesday, Senate Bill 60 passed out of the Workforce and Higher Education Committee in the morning and was then passed out of the full Senate with 20 yes votes and 11 no votes, which means OPPA and its members did an excellent job of educating lawmakers about our concerns. 

The bill now moves onto the House, where the process will begin again with committee hearings, etc. This process is far from over, the bill will have to be passed out of the House and signed by the governors prior to the end of the year before anything becomes law. Even if the bill makes it across the finish line, there will be a robust regulatory process which OPPA will be actively engaged in. We believe it will be several years before any potential program will even be up and running.

Below is a rundown on what the proposal will now look like in its entirety.  As you can see, we believe with all the change we were able to incorporate, our ultimate goal of protecting physicians but mainly patients, has been accomplished. Please note, this is not a legal analysis, but more of a general overview:

- CMHA must be under the supervision, control and direction of a physician. The services rendered by a CMHA must be within their supervising physician’s normal course of practice and expertise.

- No physician can supervise more than 5 CMHA at one time (mirroring the language we have for APRNs and PAs)

- CMHA must wear a nametag when on duty clearly identifying themselves as a “Certified Mental Health Assistant.”

- CMHA will be licensed and regulated by the State Medical Board. Bill includes numerous details about licensure and disciplinary actions the state medical board can take. Bill also establishes specific requirements around reinstating a license that has expired or lapsed.

- In order to apply for licensure a CMHA must be:

• 18 years of age
• Have completed a 4 year under graduate degree program
• Have completed 30 credit hours of a CMHA master’s program

- All CMHA educations programs must follow ARC-PA accreditation standards (see attached) and must include additional education courses in the following:

1. Psychiatric diagnoses included in the diagnostic and statistical manual of mental disorders published by the American Psychiatric Association;
2. Laboratory studies used in diagnosing or managing psychiatric conditions;
3. Medical conditions that mimic or present as psychiatric conditions;
4. Medical conditions associated with psychiatric conditions or treatment;
5. Psychopharmacology, including treatment of psychiatric conditions, interactions, and recognition and management of drug side effects and complications;
6. Psychosocial interventions;
7. Conducting suicide and homicide risk assessments;
8. Forensic issues in psychiatry;
9. Basic behavioral health counseling; and
10. Clinical experiences in inpatient psychiatric units, outpatient mental health clinics, psychiatric consultation and liaison services, and addiction services.

- A committee will be established though the medical board, made up of physicians who are appointed through recommendation from OSMA, who will review all CMHA program curriculums before curriculums are sent to Ohio Department of Higher Ed for accreditation.

- CMHA must have 12 hours of CE in Pharmacology every 2 years. Medical Board can establish through rules any other CE requirements they believe a CMHA needs.

- Scope

• Ordering diagnostic, therapeutic, and other medical services as appropriate based on a patient's diagnosis that has been made by the supervising physician
• Ordering, prescribing, personally furnishing, and administering drugs and medical devices in accordance with the diagnosis that has been made by the supervising physician
• Permitted to provide telemedicine services

- Prohibitions

• Making an initial diagnosis
• Treating a patient for any diagnosis or condition not found in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, or a similar publication if designated by the board
• Engage in electroconvulsive therapy, transcranial magnetic stimulation, or any other intervention designated as invasive by the medical board's rules
• Practicing outside of the established scope of practice

- Supervisory agreements must include:

• The responsibilities to be fulfilled by the physician in supervising the certified mental health assistant.
• The responsibilities to be fulfilled by the certified mental health assistant when performing services under the physician's supervision.
• Any limitations on the responsibilities to be fulfilled by the certified mental health assistant
• The circumstances under which the certified mental health assistant is required to refer a patient to the supervising physician.
• If the supervising physician chooses to designate physicians to act as alternate supervising physicians, the names, business addresses, and business telephone numbers of the physicians who have agreed to act in that capacity.

- Requirements on the supervising physician:

• Supervising physician must be available for direct communication when supervising a CMHA and must be physically present at the same location as the CMHA for the first 1000 hours of practice.
• Supervising physician must personally and actively review a CMHA professional activities at least weekly.
• Supervising physician must reevaluate the patient at least every two years, sooner if the patients medical condition as changed.
• Supervising physician may perform any other reviews of a CMHA they deem necessary.

- Quality Assurance System: Medical Board must establish rules around creating a quality assurance system for CMHA that includes the following:

• Routine review by the physician of selected patient record entries made by the certified mental health assistant and selected medical orders issued by the certified mental health assistant
• Discussion of complex cases
• Discussion of new medical developments relevant to the practice of the physician and certified mental health assistant
• Performance of any quality assurance activities required in rules adopted by the state medical board
• Performance of any other quality assurance activities that the supervising physician considers to be appropriate

- Physician Delegated Prescriptive Authority

• The certified mental health assistant shall exercise physician-delegated prescriptive authority only to the extent that the physician supervising the certified mental health assistant has granted that authority.
  
  
• The certified mental health assistant shall comply with all conditions placed on the physician-delegated prescriptive authority, as specified by the supervising physician If conditions are placed on that authority, the supervising physician shall maintain a written record of the conditions and make the record available to the state medical board on request. The conditions that a supervising physician may place on the physician-delegated prescriptive authority granted to a certified mental health assistant include the following: (i) Identification by class and specific generic nomenclature of drugs and therapeutic devices that the physician chooses not to permit the certified mental health assistant to prescribe; (ii) Limitations on the dosage units or refills that the certified mental health assistant is authorized to prescribe; (iii) Specification of circumstances under which the certified mental health assistant is required to refer patients to the supervising physician or another physician when exercising physician-delegated prescriptive authority; (iv) Responsibilities to be fulfilled by the physician in supervising the certified mental health assistant that are not otherwise specified in the supervision agreement or otherwise required by this chapter.
  
  
• CMHA must register with the DEA.
  
  
• CMHA can only prescribe a controlled substance in these 3 circumstances:
  • Buprenorphine, but only for a patient that is actively engaged in opioid use disorder treatment; (state medical board will promulgate rules around restrictions of prescribing buprenorphine)
  • A benzodiazepine, but only in the following circumstances: (a) For a patient diagnosed by the supervising physician as having a chronic anxiety disorder; (b) For a patient with acute anxiety or agitation, but only in an amount indicated for a period not to exceed seven days.
  • A stimulant that has been approved by the federal food and drug administration for the treatment of attention deficit hyperactivity disorder, but only if the supervising physician has diagnosed the patient with, or confirmed the patient's diagnosis of, attention deficit hyper activity disorder.
• CMHA must query OARRS when prescribing a controlled substance.
• Medical board may also promulgate rules around the prescribing of MAT drugs, including limitations and restrictions.

- Bill requires insurance coverage through Ohio’ Medicaid program, it does not require private insurance coverage.

Again, we wish to thank all members who became actively engaged in advocacy on this important piece of legislation. We encourage all members to contact their state Representatives in the House as the bill moves through the next process. It is never too late to become engaged. And, while OPPA has taken a position of Interested Party, individual members - speaking on behalf of themselves (and not OPPA) - can continue to strongly oppose the bill if so desired.