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While Mississippi’s Board of Medical Licensure largely walked back a previous decision to allow patients to use services provided by out-of-state physicians via telemedicine, other states such as Michigan and West Virginia are removing regulatory restrictions in the wake of the coronavirus pandemic.

Michigan’s Gov. Gretchen Whitmer, a Democrat, has issued two executive orders. The first suspended the state’s certificate of need program and removed some restrictions on medical licenses and nursing assistants. The second order issued on March 29 was more thorough, with several components:

On a similar note, West Virginia’s Republican Gov. Jim Justice issued an executive order on March 19 that suspended the state’s regulations in several areas:

Mississippi has been a mixed bag. The state’s Board of Nursing issued a proclamation that allowed out-of-state nurse practitioners to use telemedicine to treat Mississippi patients without having a state license. The practitioner only needs a license in another state. The proclamation also allows practitioners licensed outside the state to complete a waiver form to practice in Mississippi.

The Mississippi Board of Medical Licensure issued an amended proclamation last week that limited telemedicine for out-of-state physicians not licensed to practice in Mississippi to only those who have an existing doctor-patient relationship rather than any licensed physician. 

On March 15, the board issued a proclamation that said it would not enforce regulations governing out-of-state physicians using telemedicine to treat patients in the state in response to an emergency declaration by Gov. Tate Reeves that urged a reduction of regulations due to the spread of the coronavirus.  

The proclamation would also have the board not enforcing its rules requiring physicians to examine patients prior to prescribing medication, including controlled substances, to encourage the use of telemedicine. That part of the proclamation is still in effect.

Under existing regulations, a physician using telemedicine to treat patients must be licensed to practice in Mississippi.

All three states are part of the Interstate Medical Licensure Compact, which has 26 states that have joined together to streamline their normal licensing process for licensed physicians. This provides physicians moving from one compact-participating state to another the ability to get a license in their new state within days rather than weeks or even months.

There are two policies that could increase the supply of hospital beds and the supply of healthcare providers in Mississippi. The first policy is certificate of need (CON). The second is telemedicine.

In part 1 of this series, we focused on what the goals of healthcare policy should be during the coronavirus outbreak and reviewed recent federal and state actions aimed at increasing supply and access. In this second part, we recommend five reforms Mississippi policymakers should make to CON laws to immediately increase bed capacity and five reforms they should make to telemed laws to increase access to qualified healthcare professionals.

Certificate of Need

A certificate of need (CON) compels would-be medical providers to demonstrate a community need for a new facility or service. In Mississippi, the Department of Health is the arbiter of this process. The problem with CON laws is that they circumvent the natural interaction between supply and demand, by which providers and consumers determine where new medical services should be offered. In place of the free market, we end up with Soviet-style, bureaucratic planning. This planning tends to be biased toward current providers and is sometimes used to block out-of-state providers from offering their services in Mississippi. The results are well documented: reduced access, lower-quality, and higher mortality rates.

In the context of the coronavirus, certificate of need laws make it more difficult for hospitals to quickly respond to patient needs. States are thus creating pathways for providers to submit emergency CON applications. Mississippi already has an emergency CON application process in place, but the current application could be customized and streamlined so that providers aren’t hindered by red tape during the current pandemic.

As things stand, Mississippi is projected to run out of ICU hospital beds as of May 3. In this respect, we are better off than most states, and for both better and worse, are at the high end of existing hospital beds per capita: 4.0 beds per 1,000 vs. a nationwide average of 2.4. This surplus could serve us well during the current outbreak. But in a nonemergency situation it suggests we are not using healthcare resources efficiently. It is also safe to assume that not every area of the state has equal access to hospital beds. Some hospitals, in an emergency, may need to ramp up supply.

A review of Mississippi’s numerous CON laws raises multiple red flags. These laws need to be suspended, not only to deal with the current coronavirus outbreak, but to create capacity for other emergency services, such as open heart surgery, ambulatory surgical services and diagnostic imaging.  

In particular, Mississippi should suspend the following five CON requirements:

This latter requirement is particularly onerous, insofar as the state is currently enforcing a moratorium on the approval of new CONs for the construction or expansion of skilled nursing facilities and intermediate care facilities.

There are likely other policies that hinder hospitals from increasing bed capacity in an emergency. Instead of forcing hospital administrators to operate in a gray area during this and future pandemics, state policymakers should act now to clarify the process by which providers can increase bed supply, especially in critical care situations. 

Telemedicine

Telemedicine has emerged as an important tool for sustaining and supporting healthcare services in the current “shelter-at-home” environment. Telemed allows patients to consult with a doctor over the phone and/or via video. 

In response to the coronavirus, Mississippi’s key licensing boards have taken divergent stands. The Board of Medical Licensure initially (see proclamation dated March 15) encouraged “all physicians to utilize telemedicine so as to avoid unnecessary patient travel, both in-state and out of state.” In order to facilitate this stated goal, the Board waived the requirement for an initial in-person examination and, also, clarified that physicians licensed in another state could treat patients in Mississippi. A few days later, however, the Board walked back from this proclamation, claiming that only out-of-state doctors with a previous patient relationship could practice telemed in Mississippi.  

By contrast, the Board of Nursing is allowing nurses who hold an out-of-state license to practice in Mississippi. The Nursing Board is also allowing recent graduates and retired nurses to practice in appropriate settings.

Mississippi took an early lead in using telemedicine to treat various conditions like diabetes, and the University of Mississippi Medical Center is using telemed in a number of innovative ways. The state is also part of various interstate compacts that make it easier for out-of-state healthcare professionals to see Mississippi patients in a telemed setting. These include the Interstate Medical Licensure Compact, the Nurse Licensure Compact, and the Physical Therapy Compact.

That said, the overall legal and regulatory environment for telemed in Mississippi is mixed. As other states are opening the door wide to telemedicine and many patients are using it for the first time, we are going to see an expansion of telemedicine services across the country both during and after the current health emergency.

Here are five things Mississippi should do to avoid falling behind:

The coronavirus has demonstrated the U.S. healthcare system is far more fragile than any of us imagined. In spite of spending more per capita than any other country, our healthcare system is suffering from personnel and supply shortages. To meet the current need, some states are cutting red tape to increase supply. Monopolistic practices – embodied by archaic policies like certificate of need requirements and telemedicine restrictions – are not only increasing prices and limiting access during normal times, they are literally crippling our ability to respond to both individual and systemic healthcare emergencies. Mississippi would do well to follow other states in lifting these restrictions during the current outbreak and in repealing them after the crisis passes.

Gov. Tate Reeves issued a statewide 'shelter-in-place' order today to help slow the spread of coronavirus in Mississippi. The order begins on Friday at 5 p.m.

The statewide order came a day after a local order in Lauderdale county.

Individuals will only be allowed to leave their house for health-related reasons, to obtain food and common household supplies, to engage in individual outdoor activity, and to work in an essential business. Those essential businesses include, but are not limited to, hospitals, healthcare facilities, grocery stores, pharmacies, child-care centers, as well as a variety of functions from sectors such as utilities, transportation, agriculture, manufacturing, and finance and banking.

The guidelines for the order include:

Mississippi’s first positive case of coronavirus was confirmed on March 11. As of April 1, that number had escalated to 1,073 as the number of people being tested continues to climb. These numbers now count tests from the state, as well as private providers. Twenty-two deaths have been reported. Using the available data, the current mortality rate is 2 percent.

All local, county, and state law enforcement officers will be able to enforce the order. The order is in effect until April 20.

As the coronavirus pandemic began to sweep across the nation, it became clear that we were critically short on certain medical necessities including hand sanitizer, masks, and ventilators. Many feared for what would be a soon to come shortfall on these items that are medically critical to prevent further spread of the virus and effectively treat those who have it. 

Thankfully, private enterprise has stepped up to the plate in a historic way. Businesses are transitioning to fill the existing gaps and provide the supplies that the country needs. In Mississippi, we have seen local business leaders bravely take risks in order to fill critical medical needs. 

A few days ago I had the chance to speak with Josh West, owner and founder of Blue Delta Jeans, a high-end clothing company based out of Oxford that creates custom order jeans, tailored to each individual.

In 2012, Josh launched Blue Delta Jeans after working in economic development. Through his previous role, he had the opportunity to work with a range of factories, and it was clear to him that while some manufacturing was moving abroad, there was a strong supply of skilled workers in North Mississippi and a demand for American-made products.

And that business has only grown in the past eight years.

Today, Blue Delta Jeans is doing things a little differently. They have fully transitioned its factory to make much-needed masks. After only two weeks of production their team is now able to construct 10,000 masks a week and are aiming even higher. While not medical-grade, these high-quality masks are designed to be used in non-acute situations, especially those in waiting rooms, grocery stores, and elsewhere, thus allowing for the medical-grade masks to be entirely used by those who need them. Once the masks are constructed, they are then shipped to government entities for statewide distribution.

If he had been told in February that Blue Delta would be making masks, Josh said to me that he never would have believed it. Yet, as the virus got worse, he heard more about the need for supplies, especially masks. So, he started looking further into it and then began contacting his local suppliers. His focus was on making the product safe, so he worked with Mississippi State University to conduct initial tests before construction of the product. Then, in just a 48-hour period, they changed the entire factory over from jeans to masks.

Blue Delta is now not only providing masks, but also continued employment, a critically important need for people as we undergo a continued economic slump due to the virus. Josh told me that each employee was given the opportunity to leave, and that when times returned to normal, he assured each that they would have a job waiting for them, and yet every single employee chose to stay and transition to working on masks. They are ensuring a safe work environment by placing temporary walls up and allowing each individual to practice social distancing while sewing the masks.

Blue Delta has been able to keep people employed and has even sought to hire more workers in order to expand their capacity for mask construction. The power of a steady paycheck is critically important for those seeking to provide for their families during this time of need. And so, in this way, Blue Delta Jeans has fulfilled a dual need both through their support of their workers and supports of thousands of people through the construction of their masks.

This local clothing company, that started in 2012 with just one seamstress, is now making 10,000 masks a week to support the community. Josh West and his company highlight what’s great about Mississippi and this country.

As we closed the conversation, Josh noted that, “[h]opefully we’ll be making jeans again one day.” Neither Josh nor I are certain when this crisis will end, but even once the Blue Delta Jeans factory is back to its normal line of work, I don’t think anyone will soon forget what they did for the state.

These businesses that are stepping up deserve to be highlighted, and so the Mississippi Center for Public Policy is launching a series dedicated to doing just that. Over the coming weeks, we aim to showcase the stories of these local businesses who have willingly given up their normal operating procedures to help as many people as they possibly can.

If you know of a local Mississippi business that is helping those in need during this critical time, we’d love to highlight the work that they’re doing. Please email Hunter Estes via [email protected] to discuss further.

Mississippi’s two largest cities – Jackson and Gulfport – are issuing orders for residents to stay at home in light of the coronavirus pandemic.

In Jackson, Mayor Chokwe Antar Lumumba will make the announcement at a press conference later today. Hinds county has the most cases in the state at 90, which is about 10 percent of the total cases in Mississippi.

Mayor Billy Hewes is issuing a similar order for Gulfport. Hewes said this is necessary because too many people aren’t following limitations on gathering sizes. 

“This selfishness is unfair to those who have been acting in good faith, and has now put our community at risk,” Hewes told the Sun Herald.  “It is because of these activities that we are now forced to implement additional measures to protect the public. This is anything, but ‘business as usual.’”

Violators of the order in Gulfport can receive a $300 fine and/ or jail time.

Tupelo and Holly Springs have issued similar orders and on Tuesday Gov. Tate Reeves issued a lockdown order for residents in Lauderdale county because of a rapid rise in positive COVID-19 cases in the county, including an outbreak at a local nursing home.

What are stay at home orders?

Generally speaking, these orders close nonessential businesses and only allow residents to leave their home for specific, approved needs.

Under an order, you can still shop for groceries, pick up medications, pick up food from a restaurant, help family members in need, and exercise outdoors. 

Essential businesses include hospitals, healthcare facilities, grocery stores, pharmacies, child-care centers, as well as a variety of sectors such as utilities, transportation, and finance and banking. 

Alcohol delivery apps have seen a boom in sales in the states where they are legal since the outbreak of coronavirus. This doesn’t include Mississippi. 

Drizly is an alcohol delivery app that lets you place an order for your favorite beer, wine, or liquor based on your location, and get it delivered to your front door. Drizly operates in 26 states plus the District of Columbia.

In the middle of March, their sales were up approximately 300 percent from the prior year. And that is mostly driven by new customers, who accounted for more than 40 percent of sales in March compared to the normal 15 percent.

Same story with Mininbar Delivery, another app that allows you to place an order to have alcohol delivered. They operate in 18 states. From March 11-16, there sales were up 131 percent from the prior week. 

Helping to drive the increase in sales were larger orders that came with a price tag 20 percent higher than usual. 

In light of the coronavirus pandemic, the Mississippi Department of Revenue has eased off a couple regulations to make it easier to purchase alcohol. Curbside pickup is available at liquor stores and you can order a bottle of wine with your to-go order from a restaurant. 

Just not delivery. 

For now, Mississippians cannot partake in the convenience of technology that allows their neighbors to order their drinks online or on their phone. 

Gov. Tate Reeves announced today that he is issuing a ‘shelter-in-place’ order for Lauderdale county to slow the spread of the coronavirus outbreak. 

This is the first locality that Reeves has issued a stay at home for after announcing that isolated orders would be coming soon. Lauderdale county has been identified by the Department of Health as a region that is at higher risk for transmission of COVID-19 after a rapid increase in positive cases in recent days. Reeves and other health officials noted an outbreak at a nursing home in the county.

The order remains in place for 14 days. 

The guidelines for the order are as follows:

Prior to statewide action, the cities of Holly Springs and Tupelo had implemented local stay at home orders. 

Last week, Reeves issued a statewide order stopping dine-in services at restaurants, unless there are 10 or less people present, and mandated social distance practices are being followed. 

More counties are expected to receive similar orders in the coming days. 

To implement lessons learned from the unprecedented emergency caused by the spread of the coronavirus, there are numerous long-term strategies we encourage Mississippi legislators and leaders to tackle to ensure a prosperous future for all.  

These aren’t different than what Mississippi Center for Public Policy has long advocated. But as the current pandemic crystalized, we witnessed how government regulations often got in the way and stymied the help they are designed to provide. This was true in the past, it is true today, and will be true in the future. 

Healthcare:

1. Repeal CON laws

Certificate of Need laws require would-be medical providers to prove — essentially to their competitors — that their community needs a new facility or service. And they are one of the reasons we see a shortage of hospital beds during a time of crisis. The Mississippi Department of Health is the central planner tasked with administering the state’s CON program. The Department’s CON Review program applies to “the establishment of new healthcare facilities, the offering of defined new institutional health services, and the acquisition of major medical equipment.” In some cases, new CONs have not been issued for decades because of government mandated prohibitions. Healthcare facilities shouldn’t have to ask the state for permission to open or expand a facility. 

Read more about Certificate of Need laws

2. Expand scope of practice

Current regulations prevent nurse practitioners from practicing up to their full practice authority. Rather, they are required to enter into a “collaborative agreement” with a physician if an APRN wishes to open their own clinic. APRNs should be allowed to practice without this agreement. 

Read more about scope of practice

3. Allow out-of-state medical professionals to provide telemedicine

Mississippi has been recognized as a leader in telemedicine, something that is vitally important in a rural state. But as with most healthcare regulations, they are designed to favor incumbents. The state should allow patients to access out-of-state medical professionals for telemedicine services. This was a change the Board of Licensure temporarily made, before the regulation was updated to only allow telemedicine appointments for those who had a prior patient-doctor relationship. Mississippians should be able to access the doctor or nurse practitioner of their choosing, regardless of the state they are licensed. 

4. Expand Right-to-Try in Mississippi

Right to Try laws gives terminally ill patients the ability to try medicines that have not yet been approved by the federal government for market. Mississippi enacted Right to Try legislation in 2015, part of a movement that has swept across the country. The state should expand the current list of eligible patients to an individual with a traumatic injury and to allow adult stem cells as a treatment option, as pending legislation would allow. This would expand upon the current individual freedoms for terminally ill patients who have exhausted their government-approved options and are simply looking for another option. 

Licensing and regulations:

5. Require a full regulatory audit of every agency to provide regulatory relief

Pending legislation would require a regulatory audit of four agencies in the state. That should be expanded to every agency in the state to provide a full picture of our regulatory burden. As we have seen, numerous regulations hinder access to healthcare and our ability to use technology for services, ranging from medical supply delivery via drones to alcohol delivery. Additionally, going forward, for every new regulation an agency adopts, two should be removed as we work to scale down the 117,000 regulations in the state. 

Read more about government regulations

6. Permit the OLRC to review, and potentially replace, all regulations

Pending legislation would allow the Occupational Licensing Review Commission to review and replace past regulations. This should be adopted to ensure overburdensome regulations that hamper economic growth and prevent competition are removed from the books. We have seen numerous state and federal regulation temporarily removed. This should be done on a regular basis and should be permanent. 

7. Recognize all out-of-state occupational licenses

Professionals who are trained in another state generally have to jump through numerous hoops to work in Mississippi. If someone has received an occupational license in another state, the state should recognize that license and allow them to immediately work in Mississippi.

Read more about occupational licensing

8. Enable commercial drones for medical supply deliveries

In numerous locations around the globe, commercial drones play a key role in delivering medical supplies. This could serve a critical need in the state. But for that to happen in Mississippi we need to change multiple regulations concerning our airspace lease laws, laws vesting air rights with landowners, and our avigation easement law. 

Read more about drones

9. Modernize the DMV

Before the coronavirus outbreak, wait times at the DMV were already a major inconvenience, at the least. We should allow technology to automate the DMV and only have customer service reps to provide backup, if needed. Today, kiosks have technology to read documents containing your new address if you need to renew your license and your address has changed. If you moved from out of state, they can quickly confirm your current license from that state. If your license is suspended or you owe back fees, the kiosk will recognize that. If you are getting a license for the first time, they will be able to serve you. You could even take your exam at the kiosk. They can take pictures. They can do vision exams. They can accept cash, checks, or credit cards. When it comes to getting a driver’s license, it shouldn’t be a challenge. Or require a day off from work. 

Read more about modernizing DMVs

Education:

10. Enable online learning in Mississippi

Mississippi has a very limited public virtual school, but no full-time options for students wishing to pursue that course, emergency or not. Yet, as the education future continues to develop, we will continue to see a demand for online learning. With online learning options, students literally have the world at their fingertips. Whether it’s a unique subject with hard-to-find instructors, a class they need more help with, or one that they are wishing to dive deeper into, the ability to use technology to transform education is very real. Mississippi should work to expand the current Virtual Public School to make it full-time and remove the prohibition on virtual charter schools to provide parents with more options.

Read more about online learning

In times of crisis, there is likely to be a desire among some to expand government power. But as we’ve seen with this pandemic, it is the overburdensome government rules and regulations that tended to get in the way. Yet, this happens every day of the year. Now is the time to roll back regulations that prevent people from earning a living, accessing the healthcare they need, or using technology to make all of our lives easier and better. 

For more on our vision for Mississippi’s future, read the High Road to Freedom. 

As Mississippi battles the outbreak of coronavirus, a study that ranks states on their openness and access to healthcare places the state mid-pack nationally.

The Healthcare Openness and Access Project, authored by three scholars from the Mercatus Center at George Mason University, ranked Mississippi 24th. The study measures the extent of control a state exercises over healthcare and the authors used 41 different indicators grouped in five categories.

The authors — Jared Rhoads, Dr. Darcy Bryan M.D., and Robert Graboyes — scored each state in each indicator on a 1 to 5 scale, with 5 being the best score. Then the scores for each indicator were averaged in their categories. Each state’s total score is an average of the five categories. Mississippi scored a 3.29, slightly above the national average of 3.27.

Rhoads said the new edition has some differences over the first index released in 2018, including moving some indicators from one category to another and reducing the number of categories from 10 to five.

“The result is more easily digestible now and what we’re hearing from readers and reviewers, it is a more intuitive way of organizing the data,” Rhoads said. “We wanted to give a general feel on how restrictive a state is versus how much it can liberate people to do what they think is best.”

In the professional regulation category, Mississippi scored well (3.40, above the U.S. average of 3.14) for being part of the Interstate Medical Licensure Compact (29 states participate), fewer optician licensing requirements and broad scope of practice for behavioral health providers and midwives. It scored poorly on scope of practice for dental hygienists and overly restrictive licensing of certified registered nurse anesthetists.

In the institutional regulation category, Mississippi scored a 2.83, below the national average of 2.96. This category measures how much control state regulators impose over the business operations of healthcare institutions such as hospitals and pharmacies.

The state’s certificate of need program has more restrictions than most, receiving a score of 2. The state’s hospital taxes (up to $2 per patient bed per day) and raft of restrictions on compounding pharmacies also drew low marks from the study authors.

Mississippi law requires CON approval for all projects that increase the bed complement or a capital expenditure of at least $2 million. CON approval is also required for major medical equipment purchases of more than $1.5 million and is not a replacement for existing equipment. Mississippi is one of 35 states that requires a certificate of need.

Rhoads said that Mississippi’s CON laws were one area that policymakers could make a big change to the state’s rating. He also said that even just chipping away at some of the restrictions (such as a law that passed a few sessions ago that didn’t require CON approval for capital expenses related to natural disasters) would be a positive way to impact the state’s healthcare access.

There were three bills filed that would’ve eliminated the CON program in this year’s legislative session, but all three died in committee without making it to the floor for a vote.

Mississippi also scored lower (2.83) than the national average (3.10) on patient regulation, which is defined as easier access by patients to certain types of drugs and other patient-oriented protections.

The state was penalized for not allowing oral contraceptives unless prescribed by a physician and a lack of a free speech in medicine law. The state received top marks for protecting good Samaritans and lower taxes on e-cigarettes. 

In the payment regulation category, Mississippi received high marks for not having an individual mandate to require individuals buy health insurance, has fewer health savings account taxes, doesn’t restrict short-term, renewable health insurance plans, and allows drug manufacturer copay coupons. Mississippi received low marks for not allowing insurers in other states to issue policies in the state and its ban on reimportation of prescription drugs. 

Mississippi also received high marks for not having a lot of regulations on direct primary care plans. These plans enable doctors to bill patients directly for services. This bypasses traditional health plans, where a third party pays most of the cost while the insured pays a smaller amount. The state also received high marks for reimbursing Medicaid providers at parity for remote monitoring.

A bill that would’ve kept these plans from being regulated as an insurance product by the state Department of Insurance died in the Senate without a floor vote.

Healthcare Openness and Access Project 2020: State rankings

Mississippi scored better than its neighbors overall. Louisiana had the next best overall score, ranked 30th. Alabama was ranked 35th, while Tennessee was slightly higher at 33rd. Arkansas was 40th.

New Jersey, Massachusetts and New York were the least free states overall, while Colorado, Arizona and Utah were the freest. 

The HOAP index has been released earlier than planned. The 2020 edition of the HOAP was supposed to come out in June, but the authors pushed up its release considering the coronavirus pandemic. 

This version is an early, non-peer reviewed version that was released early to help policymakers with information to remove healthcare restrictions to help fight the COVID-19 pandemic. A full, peer-reviewed version will be released later this year.

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