Hospitals weigh medical marijuana options

Dave Dillon, Missouri Hospital Association vice president of public and media relations, speaks about medical marijuana and the effects it will have on hospitals.
Dave Dillon, Missouri Hospital Association vice president of public and media relations, speaks about medical marijuana and the effects it will have on hospitals.

To be clear, no doctors in Missouri will be prescribing medical marijuana.

By federal law, that would be illegal.

What doctors can do is certify their patient has a condition.

And it may be difficult to find doctors in Jefferson City who are willing to certify their patients' conditions so they may seek out medical marijuana.

Capital Region Medical Center's medical group "continues to evaluate this new legislation thoroughly" so it may establish policies that align with the health care provider's obligations to provide safe, effective health care, according to Lindsay Huhman, CRMC's director of marketing.

More than eight months after Missouri voters overwhelmingly passed Amendment 2 - which lays out the process for growing, manufacturing and dispensing medical marijuana - confusion remains, particularly where it comes to the connections between patients, their doctors and what some people are calling "prescriptions" for medical marijuana.

Nobody in Missouri will receive a prescription for medical marijuana.

Instead, qualified patients will receive a medical marijuana card.

Missouri voters last November - by a 2-to-1 margin - legalized marijuana use for treatment of cancer; epilepsy; glaucoma; intractable migraines (those persistent migraines that don't respond to other treatments); chronic medical conditions that cause severe, persistent muscle spasms, including, but not limited to those associated with multiple sclerosis, seizures, Parkinson's disease and Tourette syndrome; debilitating psychiatric disorders (when diagnosed by a state licensed psychiatrist), including but not limited to post-traumatic disorders; human immunodeficiency virus or acquired immune deficiency syndrome; chronic medical conditions whose treatment could lead to physical or psychological dependence (if a physician determines cannabis would be effective and safer); any terminal illness; or (in the professional judgment of a physician) any other chronic debilitating medical condition.

 

Card carriers

To receive the card, the patient has to get a doctor to check off one or more of the aforementioned conditions on the application, which may be found on the Missouri Department of Health and Senior Services website. And that is not happening at some Jefferson City health care providers.

Although patients are finding doctors to sign off on certifications, doctors at local hospitals are not doing so at this time.

"Providers with Capital Region Physicians, Capital Region Medical Center's medical group, are not currently certifying qualifying conditions for patients wanting to obtain marijuana for medical purposes," Huhman said.

Jefferson City Medical Group released a statement Thursday, saying the group is not issuing certifications for medical marijuana "at this time as we complete our internal review process."

Officials at St. Mary's Hospital in Jefferson City said they have asked that their regional physicians (for SSM Health Mid-Missouri) not provide certificates "until a systemwide policy is finalized."

Health care providers at MU Health Care, which is in negotiations to buy St. Mary's Hospital, said its physicians are not completing the certification forms for patients wishing to obtain medical marijuana "at this time."

All the statements leave the door open for issuing certifications in the future.

The state has accepted online applications since June 28, about a week before Amendment 2 required it to do so, according to Lisa Cox, DHSS public information officer.

 

High demand

As of Wednesday, DHSS had received 3,071 applications for personal medical marijuana cards, Cox said. Of those, 3,012 were for patients and 59 for caregivers. Caregivers are required to be at least 21 years old, responsible for managing the well-being of a qualified patient, and designated on a caregiver application for an identification card.

More than 2,400 of the applications have been processed and approved, Cox said. When patients are approved, they receive their card via email in a PDF format. The card is good for one year.

Many patients are going to clinics that have been set up to help them acquire medical marijuana cards. For example, Green Health Docs employs licensed doctors in Ohio, Maryland and Missouri to help people obtain the cards, according to Randy Shaffer, Green Health marketing manager.

All of Green Health's physicians are licensed and in good standing with the state, he said.

The company has set up clinics in Kansas City, St. Louis and Columbia. It is preparing to open one in Springfield. It has already certified about 1,000 patients in Missouri.

The site with the highest quantity of patients Green Health has seen is St. Louis, closely followed by Columbia, Shaffer said.

Patients who visit Green Health are required to take their medical records. They meet with physicians and undergo an examination.

If patients don't have qualifying conditions, they are turned away.

"Most people who come in have exhausted treatments," Shaffer said. "They've tried everything. The prescription drug system has failed a lot of people."

 

Waiting for 2020

Even though Missouri patients have received their cards, they will still have to wait a little while to purchase medical marijuana. Dispensaries aren't expected to begin selling products until early in 2020.

Jefferson City health care providers are wary of the new year. As their patients begin gaining access to medical marijuana, hospital and clinic administrators will have to decide how they will navigate patients' medical marijuana waters.

"SSM Health is in the process of developing an overall systemwide medical marijuana policy with a goal of providing the highest quality care and best possible outcomes for our patients," Jessica Royston, marketing and communications manager for SSM Health's Mid-Missouri and Northwest Missouri regions, said in an email. "With state medical marijuana regulations yet to be finalized and product availability not starting in Missouri until next year, SSM Health is still in the process of developing a formal policy."

All local hospitals are struggling with policies they'll have to have in place when people start medicating themselves with cannabis.

Health care providers will have to decide if the products may be used on their campuses - and, if so, whether they as health care providers will administer marijuana or if they will allow the patients to self-administer.

 

Hospital challenges

The Missouri Hospital Association has drafted some tentative guidelines for the providers to consider. The resources, found at web.mhanet.com/medical-marijuana, offer guidance for managing employees who may receive medical marijuana cards, how the new law affects facilities and what it means for hospital policies.

The people who drafted the amendment did a good job of defining how they wanted the law to look, said Dave Dillon, MHA vice president of public and media relations.

"MHA doesn't make recommendations on clinical matter," Dillon said. "However, hospitals will be required to understand what the implications of the policy are for their organizations as both employers and providers of clinical services."

The hospital community is concerned about the new law's implications for hospitals as employers - and how to address issues of employees possibly being under the influence. And of great concern is the relationship between hospital physicians, their patients and the new law.

To that end, MHA provided legal perspectives - not counsel, because the organization doesn't technically represent hospitals - on what issues will be paramount for hospital and health-system policy development.

The organization is providing, for hospitals, on-demand education on the scope of the amendment, updates on rules developments and draft by-laws for hospital medical staff.

"It isn't really clear that hospitals are going to go one direction or the other," Dillon said. "Some hospitals have announced that they are going to prohibit physicians within their organizations to (certify conditions)."

Questions remain about what hospital policies will be in place once a patient (who has qualified for medical marijuana) is in a hospital environment, Dillon said.

The federal government continues to list marijuana as a Schedule 1 drug, meaning it has no accepted medical use and a high potential for abuse.

"Because of its status as a Schedule 1 drug, physicians and other health care providers may not prescribe, administer or dispense marijuana," the MHA website states. "The law also prohibits them from aiding or abetting the cultivation, distribution or possession of cannabis."

Although Amendment 2 protects those activities, physicians face prosecution under federal law if they participate in those activities.

At least one federal court concluded recommending medical marijuana is not aiding and abetting the patient's possession of the drug under the Controlled Substances Act, and certifying the conditions likely won't attract criminal enforcement. Despite a lack of criminal enforcement, health care providers worry some agencies could exclude them from programs. Hospitals are required to submit annual cost reports.

"If a hospital was found to have aided and abetted a patient's possession or use of medical marijuana, this attestation could be deemed a false claim under the federal False Claims Act, exposing the facility to civil and criminal liability, monetary penalties and exclusion from Medicare and Medicaid," the website states.

The site offers policy templates for health care providers to use should they choose to prohibit or allow use of medical marijuana on their campuses. And, if the provider decides to allow use of medical marijuana on campus, it must also decide if the products are self-administered or staff-administered.

"Assuming the hospital doesn't prohibit the use of medical marijuana on its campus, then how do you administer?" Dillon said. "Does the patient self-administer the drug? Do the caregivers?"

The most beneficial thing the MHA can do is identify all the issues and give information to the hospitals so they can make informed decisions about their internal policies, he said.

It is important hospitals know what the consequences of rolling out a policy poorly could be, he added. The MHA has looked at legal precedents set in other states for patients and employees.

Missouri was the 33rd state to pass some sort of medical marijuana law.

"The good part of this is we aren't at the bleeding edge of this policy," Dillon said. "Many other states have either adopted medical marijuana policy or decriminalized marijuana in general or are even allowing recreational use of marijuana. Those various experiments at the state level help inform our thinking as a community of hospitals about how this could evolve."

Missouri's law is different than some because it's a constitutional right versus a statutory change. Policymakers have to be aware if they make a mistake, they are potentially affecting someone's constitutional rights as opposed to violating a statute.

"For some people, there are shades of gray differences. A fundamental constitutional right is different than a statutory right," Dillon said.

Missouri won't fully know the implications of Amendment 2 until the new law is completely in effect - until people start to use the products.

"There will probably be aspects of it," Dillon said, "that will be litigated so there will be clarity on it."