Michigan Office of Administrative Hearings and Rules  
Administrative Rules Division (ARD)  
611 W. Ottawa Street  
Lansing, MI 48909  
Phone: 517-335-8658 Fax: 517-335-9512  
REGULATORY IMPACT STATEMENT  
and COST-BENEFT ANALYSIS (RIS)  
Agency Information:  
Department name:  
Health and Human Services  
Bureau name:  
Policy and Legislative  
Name of person filling out RIS:  
Mary Brennan  
Phone number of person filling out RIS:  
517-284-4850  
E-mail of person filling out RIS:  
Rule Set Information:  
ARD assigned rule set number:  
2021-31 HS  
Title of proposed rule set:  
Michigan Physician Orders for Scope of Treatment  
Comparison of Rule(s) to Federal/State/Association Standard  
1. Compare the proposed rules to parallel federal rules or standards set by a state or national licensing agency or  
accreditation association, if any exist.  
There are no federal rules or standards regarding the creation of the POST form. POST is a part of the National  
Physician Orders for Life Sustaining Treatment (POLST) Paradigm. Nationally, POLST is a movement to allow  
Americans better tools in communicating their healthcare wishes. POLST is a portable medical order set used in many  
states to allow individuals with serious, life-limiting conditions to communicate preferences on resuscitation,  
intubation, and artificially administered nutrition and hydration. Michigan has chosen to adopt national standards for  
the creation and utilization of this form. POLST has different names in different states. In Michigan, we call it  
Michigan Physician Orders for Scope of Treatment, or MI-POST.  
A. Are these rules required by state law or federal mandate?  
These rules are required by state law pursuant to MCL 333.20919, 333.20192a.  
B. If these rules exceed a federal standard, please identify the federal standard or citation, describe why it is  
necessary that the proposed rules exceed the federal standard or law, and specify the costs and benefits arising out  
of the deviation.  
There is no federal standard for these rules.  
2. Compare the proposed rules to standards in similarly situated states, based on geographic location, topography,  
natural resources, commonalities, or economic similarities.  
MCL 24.245(3)  
RIS-Page 2  
Indiana instituted a similar POST program. Comparing Michigan’s proposed rules with Indiana, they do appear to be  
very similar and accomplish similar requirements to legally complete these medical orders in coordination with the  
patient. The Indiana POST Program is an advance care planning tool that helps ensure treatment preferences are  
honored. It is designed for patients with advanced chronic or terminal illness or frailties. Preferences for life  
sustaining treatments including resuscitation, medical interventions (e.g., comfort care, hospitalization, intubation,  
mechanical ventilation), antibiotics, and artificial nutrition are documented as medical orders on the POST form. It  
must be reviewed and signed by a physician, advance practice nurse, or physician assistant to be activated. This form  
transfers throughout the health care system and the orders are valid in all settings.  
A. If the rules exceed standards in those states, please explain why and specify the costs and benefits arising out of  
the deviation.  
The proposed rules do not exceed standards in the other states with legislation.  
3. Identify any laws, rules, and other legal requirements that may duplicate, overlap, or conflict with the proposed  
rules.  
The proposed rules do not duplicate, overlap, or conflict with laws, rules, or other legal requirements.  
A. Explain how the rules have been coordinated, to the extent practicable, with other federal, state, and local laws  
applicable to the same activity or subject matter. This section should include a discussion of the efforts undertaken  
by the agency to avoid or minimize duplication.  
The POST form contains a medical order regarding the initiation of resuscitation if the patient suffers cessation of  
both spontaneous respiration and circulation, and the emergency medical services personnel has actual notice of a do-  
not-resuscitate order that was executed under the Michigan do-not-resuscitate procedure act, 1996 PA 193, MCL  
333.1051 to 333.1067, after the POST form was validly executed. As used in this subdivision, "actual notice" means  
that term as defined in section 2 of the Michigan do-not-resuscitate procedure act, 1996 PA 193, MCL 333.1052. If a  
POST form is validly executed after a do-not-resuscitate order is executed under the Michigan do-not-resuscitate  
procedure act, 1996 PA 193, MCL 333.1051 to 333.1067, the medical orders indicated on the POST form are  
presumed to express the patient's current wishes.  
4. If MCL 24.232(8) applies and the proposed rules are more stringent than the applicable federally mandated  
standard, provide a statement of specific facts that establish the clear and convincing need to adopt the more  
stringent rules.  
MCL24.232(8) does not apply to these proposed rules.  
5. If MCL 24.232(9) applies and the proposed rules are more stringent than the applicable federal standard,  
provide either the Michigan statute that specifically authorizes the more stringent rules OR a statement of the  
specific facts that establish the clear and convincing need to adopt the more stringent rules.  
MCL24.232(9) does not apply to these proposed rules.  
Purpose and Objectives of the Rule(s)  
6. Identify the behavior and frequency of behavior that the proposed rules are designed to alter.  
MI-POST is intended for use by an attending health professional and only for those elderly patients with advanced  
illness for whom, based on his or her current medical condition, death would occur within one year.  
A. Estimate the change in the frequency of the targeted behavior expected from the proposed rules.  
MI-POST is an optional form for people with serious advanced illness or frailty. It is part of an advance care planning  
process. It is intended to guide care only if the person cannot tell others what to do at that time.  
B. Describe the difference between current behavior/practice and desired behavior/practice.  
The form is not currently available and the rules provide the authority for the creation and utilization of the MI-POST  
form.  
With the creation of the MI-Post form, a physician’s creates an active order set for the patient’s current medical  
condition, which also include resuscitation and treatment decisions. They help ensure that the decisions of a patient  
are followed, even if the patient later lacks capacity to make decisions. Seriously ill or frail patients, especially those  
whose attending health professionals would not be surprised if they were to die within a year, are encouraged to  
complete a MI-POST form. The form takes the patient’s decisions and puts them into a physician’s order set that can  
be followed at any Michigan health care facility, as well as by first responders.  
C. What is the desired outcome?  
MCL 24.245(3)  
RIS-Page 3  
The desired outcome is to help health care professionals honor the treatment decisions of their patients through the  
creation of portable medical orders. Improve the quality of care through the reduction of medical errors through  
informed consent and allowing decisions to be made in advance.  
7. Identify the harm resulting from the behavior that the proposed rules are designed to alter and the likelihood  
that the harm will occur in the absence of the rule.  
MI-POST fills a gap that cannot be met by an advance directive, or an out-of-hospital Do-Not-Resuscitate (DNR)  
form. Emergency Medical Services are required by law to provide aggressive treatment unless otherwise directed by a  
medical order. In the absence of a POST form patients will receive advanced cardiac life support, including  
cardiopulmonary resuscitation, endotracheal intubation, and defibrillation by emergency medical personnel based on  
standard protocols. In addition, DNR forms specifically address cardiac life support and are only applicable when a  
person is not breathing and has no pulse. The MI-POST form is more specific and addresses additional medical  
interventions such as intubation, transport, antibiotics, cardioversion, tube feeding and hospitalization.  
A. What is the rationale for changing the rules instead of leaving them as currently written?  
These are new rules in compliance with MCL 333.5676.  
8. Describe how the proposed rules protect the health, safety, and welfare of Michigan citizens while promoting a  
regulatory environment in Michigan that is the least burdensome alternative for those required to comply.  
Michigan’s Physician Orders for Scope of Treatment (MI-POST) form is an advance care planning tool that would  
include a patient’s medical condition, the signatures of the patient or patient representative and attending health  
professional, and a list of the treatments that may be administered outside of a hospital. The form ensures patients with  
an advance illness have their resuscitation and treatment decisions documented. Advanced illness means a medical or  
surgical condition with significant functional impairment that is not reversible by curative therapies and that is  
anticipated to progress toward death despite attempts at curative therapies or modulation.  
9. Describe any rules in the affected rule set that are obsolete or unnecessary and can be rescinded.  
There are no rules in the affected rule that are obsolete or unnecessary that can be rescinded. This is a new rule set.  
Fiscal Impact on the Agency  
Fiscal impact is an increase or decrease in expenditures from the current level of expenditures, i.e. hiring additional staff,  
higher contract costs, programming costs, changes in reimbursements rates, etc. over and above what is currently  
expended for that function. It does not include more intangible costs for benefits, such as opportunity costs, the value of  
time saved or lost, etc., unless those issues result in a measurable impact on expenditures.  
10. Please provide the fiscal impact on the agency (an estimate of the cost of rule imposition or potential savings  
for the agency promulgating the rule).  
Analysis of the bills determined a modest one-time fiscal implication for the Michigan Department of Health and  
Human Services (MDHHS) to establish an initial ad hoc advisory committee, develop a standardized POST form,  
promulgate rules for the use of a POST form and circumstances under which a POST form is considered valid, and  
establish a follow-up ad hoc advisory committee in 3 years. Regional medical control authorities must establish  
protocols for complying with the new Part 56B for local emergency medical services, in coordination with MDHHS,  
which may have one-time modest cost implications for those entities. Any of these fiscal impacts have already been  
realized and we would expect no significant fiscal impact on MDHHS or healthcare professionals.  
11. Describe whether or not an agency appropriation has been made or a funding source provided for any  
expenditures associated with the proposed rules.  
There will be minimal fiscal impact. MDHHS will develop administrative rules and will need to maintain  
information on our website. This information will need be updated periodically. This will require a small portion of  
employees’ time to maintain. An appropriation or funding source is not necessary due to the minimal fiscal impact  
provided by these rules.  
12. Describe how the proposed rules are necessary and suitable to accomplish their purpose, in relationship to the  
burden(s) the rules place on individuals. Burdens may include fiscal or administrative burdens, or duplicative  
acts.  
The proposed rules are being created due to legislative mandate under MCL 333.20919. There is no anticipated  
burden on the agency or an individual(s) in completing the form and having health facilities and professionals  
document the advanced care planning tool in an individual’s history; whether electronic or paper file.  
MCL 24.245(3)  
RIS-Page 4  
A. Despite the identified burden(s), identify how the requirements in the rules are still needed and reasonable  
compared to the burdens.  
Any burdens are speculative and appear to be minimal.  
Impact on Other State or Local Governmental Units  
13. Estimate any increase or decrease in revenues to other state or local governmental units (i.e. cities, counties,  
school districts) as a result of the rule. Estimate the cost increases or reductions for other state or local  
governmental units (i.e. cities, counties, school districts) as a result of the rule. Include the cost of equipment,  
supplies, labor, and increased administrative costs in both the initial imposition of the rule and any ongoing  
monitoring.  
There is no anticipated increase or decrease in revenues for other state or local government units.  
14. Discuss any program, service, duty, or responsibility imposed upon any city, county, town, village, or school  
district by the rules.  
There is no impact of any program, service, duty, or responsibility imposed on any city, county, town, village, or  
school district by the rules.  
A. Describe any actions that governmental units must take to be in compliance with the rules. This section should  
include items such as record keeping and reporting requirements or changing operational practices.  
No changes are needed for governmental units to be in compliance with these rules.  
15. Describe whether or not an appropriation to state or local governmental units has been made or a funding  
source provided for any additional expenditures associated with the proposed rules.  
There are no additional expenditures for state or local government units required, therefore, no appropriation was  
provided.  
Rural Impact  
16. In general, what impact will the rules have on rural areas?  
The rules will not have any significant impact on rural areas. MI-POST is designed to ensure that seriously ill  
patients can choose the treatments they want and that their wishes are honored by medical providers. A key  
component of the system is thoughtful, facilitated advance care planning conversations between health care  
professionals and patients and those close to them. Completion of a MI-POST form requires shared decision making  
between the health care professional signing the form and the patient, or his/her legally authorized health care  
representative.  
A. Describe the types of public or private interests in rural areas that will be affected by the rules.  
Rural medical practices will have to enter the form into a patient’s medical records.  
Environmental Impact  
17. Do the proposed rules have any impact on the environment? If yes, please explain.  
The rules do not have an impact on the environment.  
Small Business Impact Statement  
18. Describe whether and how the agency considered exempting small businesses from the proposed rules.  
No exemptions were considered as it would discriminate against certain populations that, if not for the size of a  
business in their area, would not be able to request these medical orders to be documented.  
19. If small businesses are not exempt, describe (a) the manner in which the agency reduced the economic impact  
of the proposed rules on small businesses, including a detailed recitation of the efforts of the agency to comply  
with the mandate to reduce the disproportionate impact of the rules upon small businesses as described below (in  
accordance with MCL 24.240(1)(a-d)), or (b) the reasons such a reduction was not lawful or feasible.  
The requirement to comply with these rules is the minimum required by statute for all businesses. The impact is  
anticipated to be minimal given the statute’s parameters.  
MCL 24.245(3)  
RIS-Page 5  
A. Identify and estimate the number of small businesses affected by the proposed rules and the probable effect on  
small businesses.  
This will impact all small medical practices statewide. Number is unknown, but fiscal impact is minimal.  
B. Describe how the agency established differing compliance or reporting requirements or timetables for small  
businesses under the rules after projecting the required reporting, record-keeping, and other administrative costs.  
The only administrative action is placing the form in a patient’s records. All providers regardless of size do this for  
other patient information. Costs are typically accounted for within standard medical code billing to insurance.  
C. Describe how the agency consolidated or simplified the compliance and reporting requirements for small  
businesses and identify the skills necessary to comply with the reporting requirements.  
The requirement is the minimum required by statute for all medical practices.  
D. Describe how the agency established performance standards to replace design or operation standards required  
by the proposed rules.  
Health facilities and health providers will use the MI-POST form created by the department documenting a patients’  
treatment decisions and the performance standard for the business is to document that decision in a patient’s medical  
record.  
20. Identify any disproportionate impact the proposed rules may have on small businesses because of their size or  
geographic location.  
There is no known disproportionate impact on small institutions because of their size or geographic location.  
21. Identify the nature of any report and the estimated cost of its preparation by small businesses required to  
comply with the proposed rules.  
There is no known disproportionate impact on small institutions due to these proposed rules.  
22. Analyze the costs of compliance for all small businesses affected by the proposed rules, including costs of  
equipment, supplies, labor, and increased administrative costs.  
There do not appear to be any additional costs for small institutions to comply with these proposed rules.  
23. Identify the nature and estimated cost of any legal, consulting, or accounting services that small businesses  
would incur in complying with the proposed rules.  
The agency does not anticipate any additional legal, consulting, or accounting service costs with these proposed  
rules.  
24. Estimate the ability of small businesses to absorb the costs without suffering economic harm and without  
adversely affecting competition in the marketplace.  
The agency does not anticipate any economic harm and adverse effects to competition in complying with these  
proposed rules.  
25. Estimate the cost, if any, to the agency of administering or enforcing a rule that exempts or sets lesser  
standards for compliance by small businesses.  
The proposed rules do not exempt nor set lesser standards for compliance by small businesses.  
26. Identify the impact on the public interest of exempting or setting lesser standards of compliance for small  
businesses.  
The impact on the public interest by exempting or setting lesser standards for small businesses would create an  
inconsistent availability for patients in small health business settings to utilize the form and be able to make medical  
decisions on their own regarding DNR and other life-saving procedures. The use of the MI-POST form is intended  
to be universally available to all businesses, small or large.  
27. Describe whether and how the agency has involved small businesses in the development of the proposed rules.  
MDHHS is required by statute under MCL 333.5675 to establish an ad-hoc rules committee with representatives of  
organizations to be on this committee. MDHHS’ MI POST committee was comprised of 11 members, including  
multiple representatives from medical provider stakeholder groups.  
A. If small businesses were involved in the development of the rules, please identify the business(es).  
Honoring Healthcare Choices; Burcham Hills; IHA Palliative Care; Gogebic Medical Center.  
Cost-Benefit Analysis of Rules (independent of statutory impact)  
28. Estimate the actual statewide compliance costs of the rule amendments on businesses or groups.  
MCL 24.245(3)  
RIS-Page 6  
Statewide compliance costs are expected to be minimal. The time of a medical professional to complete the form  
should be able to be included within a medical procedure billing code.  
A. Identify the businesses or groups who will be directly affected by, bear the cost of, or directly benefit from the  
proposed rules.  
Healthcare Association of Michigan, Michigan Health and Hospital Association, Michigan Home Care and Hospice  
Association, MI Assoc. of Family Physicians, Emergency Medical Personnel, Palliative Care Providers, Long term  
care providers, and health care professionals.  
B. What additional costs will be imposed on businesses and other groups as a result of these proposed rules (i.e.  
new equipment, supplies, labor, accounting, or recordkeeping)? Please identify the types and number of businesses  
and groups. Be sure to quantify how each entity will be affected.  
No additional costs are anticipated.  
29. Estimate the actual statewide compliance costs of the proposed rules on individuals (regulated individuals or  
the public). Include the costs of education, training, application fees, examination fees, license fees, new  
equipment, supplies, labor, accounting, or recordkeeping.  
There is the potential for minimal labor costs associated with compiling the form and documented it within a  
patient’s health record.  
A. How many and what category of individuals will be affected by the rules?  
All medical and EMS providers will be affected by the rules.  
B. What qualitative and quantitative impact do the proposed changes in rules have on these individuals?  
The addition of this form should be welcomed by these individuals. The original form in its most current version  
should remain the property of the individual patient. The health care facility initiating the transfer must provide  
ambulance services and the receiving facility with the MI-POST form. Paper copies are permissible and valid and  
should be made on pink paper. Facilities may retain copies of the patient’s MI-POST form. The ambulance service  
and receiving facility should honor the MI-POST if an emergency arises. The form is intended to respect the wishes  
of the patient with an advanced illness while subsequently reducing the potential for medical errors which in turn  
should lead to improving quality of care.  
30. Quantify any cost reductions to businesses, individuals, groups of individuals, or governmental units as a result  
of the proposed rules.  
The form and the associated rules are not intended to produce any quantifiable cost reductions. In the absence of a  
POST form patients will receive advanced cardiac life support, including cardiopulmonary resuscitation (CPR),  
endotracheal intubation,  
and defibrillation by emergency medical personnel based on standard protocols.  
31. Estimate the primary and direct benefits and any secondary or indirect benefits of the proposed rules. Please  
provide both quantitative and qualitative information, as well as your assumptions.  
MI-POST is intended to improve the quality of patient care and reduce medical errors by creating a system that  
identifies patients’ wishes regarding medical treatment and communicates and respects them by creating portable  
medical orders. It is based on the principles of informed consent and allows decision to be made ahead of a crisis.  
32. Explain how the proposed rules will impact business growth and job creation (or elimination) in Michigan.  
These rules will have little to no impact on business growth or job creation.  
33. Identify any individuals or businesses who will be disproportionately affected by the rules as a result of their  
industrial sector, segment of the public, business size, or geographic location.  
The health care field will have some impact by the proposed regulation. However, the impact will be minimal.  
34. Identify the sources the agency relied upon in compiling the regulatory impact statement, including the  
methodology utilized in determining the existence and extent of the impact of the proposed rules and a cost-  
benefit analysis of the proposed rules.  
House and Senate fiscal analysis; PA 157 of 2017.  
A. How were estimates made, and what were your assumptions? Include internal and external sources, published  
reports, information provided by associations or organizations, etc., that demonstrate a need for the proposed  
rules.  
House and Senate fiscal analysis documentation.  
MCL 24.245(3)  
RIS-Page 7  
Alternative to Regulation  
35. Identify any reasonable alternatives to the proposed rules that would achieve the same or similar goals.  
There are no reasonable alternatives to the proposed rules. The requirements are required by statute.  
A. Please include any statutory amendments that may be necessary to achieve such alternatives.  
There are no statutory amendments that would achieve the necessary outcomes for patients.  
36. Discuss the feasibility of establishing a regulatory program similar to that proposed in the rules that would  
operate through private market-based mechanisms. Please include a discussion of private market-based systems  
utilized by other states.  
Healthcare institutions, EMS, and other licensed health professions nationwide are regulated by state entities. It is not  
feasible to regulate these groups through private market-based mechanisms.  
37. Discuss all significant alternatives the agency considered during rule development and why they were not  
incorporated into the rules. This section should include ideas considered both during internal discussions and  
discussions with stakeholders, affected parties, or advisory groups.  
There were no alternatives other than these rules because that is what was required by the MI-POST statute.  
Additional Information  
38. As required by MCL 24.245b(1)(c), please describe any instructions regarding the method of complying with  
the rules, if applicable.  
MDHHS will provide the form on our website with instructions for the health facilities and staff to provide to their  
patients. The original form in its most current version should remain the property of the individual patient. The health  
care facility initiating the transfer must provide ambulance services and the receiving facility with the MI-POST  
form. Paper copies are permissible and valid and should be made on pink paper. Facilities may retain copies of the  
patient’s MI-POST form. The ambulance service and receiving facility should honor the MI-POST if an emergency  
arises.  
MCL 24.245(3)  
;