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At the Capitol
March 30, 2009
Sara Noznesky, MN-AAP Lobbyist
First Committee Deadline Arrives, Focus Shifting to Budget
The first of a series of committee deadlines passed this Friday March 27. This is the Legislature’s first step in a process to begin winding down their work. For a bill to be still considered “alive” it must have passed through all non-finance or tax committees in one body or the other. The next deadline is Tuesday April 7, when bills have to be through all non-finance and tax committees in both bodies.
Following the second committee deadline the work of the Legislature shifts to longer floor sessions and work on the state budget. This is where the difficult decisions will have to be made.
The most recent budget forecast projects a $6.4 billion deficit for the next two year period. With the help of the federal stimulus that shortfall is now $4.6 billion, and the Legislature will have to pass a balanced budget through spending cuts, revenue increases, or most likely, a combination of both. With the size of the deficit, there will be plenty of pain to go around.
Governor Pawlenty has continued to promote his budget recommendations that include no new tax increases and large cuts to the health and human services programs. He no longer is recommending eligibility cuts for MA or MinnesotaCare, but he is recommending a 3% reimbursement cut, elimination of most optional benefits, and elimination of the Health Care Access Fund.
The Senate Democrats have released an outline of their recommendations to balance the budget as well. Their proposal includes a 7% across the board cut to all program areas (including K-12 education) and $2 billion in new revenues. They are arguing that this is the fairest approach so that no one program takes the brunt of the cuts.
The House Democrats most recently released their budget ideas. Their outline protects K-12 education from cuts, cuts health and human services programs between 9 and 15%, protects the Health Care Access Fund, and recommends $1.5 billion in new revenues.
These three competing plans will be now be debated and eventually melded into a final bill.
Dental Caries Prevention by Primary Care Providers
In my last update, I provided information on a bill that would require primary care providers to perform a cursory oral examination, complete a risk assessment, and apply fluoride varnish for high-risk patients over the age of one at each well child visit and episodic care visits. The bill would also require providers to give families caries prevention materials and a list of dentists who accept patients in public programs.
The House version, HF984 (Norton, DFL-Rochester), was heard March 23rd. Rep. Maria Ruud (DFL-Minnetonka) successfully offered an amendment that would require the Department of Human Services to encourage primary care providers to do the additional treatments, rather than require them to do so. The bill passed and was referred to the House Finance committee for further consideration.
The MN-AAP testified that we tremendously supportive of caries prevention and share legislators’ frustration about the availability of dentists to treat MA patients. However, we did not support placing the responsibility for certain dental services on primary care physicians.
The Senate version, SF933 (Berglin, DFL-Minneapolis) still includes the service as a mandate and remains concerning to the MN-AAP.
Child Passenger Safety One Step Closer to Law
Thursday, the full Senate passed SF99 (Carlson, DFL-Eagan) requiring children up to age eight be properly restrained while riding in vehicles. The House version, HF267 (Hortman, DFL-Brooklyn Park) is also on track. Since my last update, the bill met the policy committee deadline by passing the House Transportation and Transit Policy and Oversight Division on March 16th and the Public Safety Policy and Oversight Committee on March 26th. The bill has been referred to the House Finance committee for further consideration. Please email your representatives encouraging them to support the bill.
Let your Representative know that safety belts are not made for and do not fit kids. According 2008 Minnesota crash statistics, 386 four to seven year-olds were injured or killed in a motor vehicle crash that were not in a properly fitted booster seat. (Minnesota Department of Public Safety)
Pediatricians continue to educate parents on the use of booster seats but many parents look to our state law to determine when to graduate their child to a seatbelt. Updating the law sends parents a clear message about the importance of having their child properly restrained. Forty-four states have stronger child passenger restraint laws than Minnesota. Even our neighbors in Wisconsin, Iowa and North Dakota have enacted requirements that children be properly restrained for their age.
Last night, KARE 11 ran a feature about the child passenger safety law passing the Senate. You can read the text and watch the video at the following site: www.kare11.com
Newborn Screening Moves Forward
This year’s newborn screening bill also met the first deadline by successfully making it through all necessary House policy committees. HF1341 (Thissen, DFL-Minneapolis), passed the House Health and Human Services Policy Committee on March 19th then the Civil Justice Committee this passed Monday. The goal of the bill is to make sure the newborn screening program, which uses 10 different tests to screen for 54 types of diseases, is consistent with Minnesota’s Genetic Privacy Law, which went into effect in 2006.
The bill, sponsored by the Minnesota Department of Health, would require providers to inform parents that they can object to the genetic test or to the storage of their child’s blood sample and allow the department to store specimens for two years before destroying them. Key components of the bill provide parents with additional options related to testing and storage of specimens and explicitly defines allowable research on specimens to be limited to quality control, quality assurance, and new test development. The bill would allow the department to store specimens longer than two years if parents provided written consent.
Over the last three years, there has been much wrangling on the topics of screening and sample storage at the Legislature. The debate at the Legislature has hinged on whether the law should require parents to opt into the program or opt out of the program and whether the state should keep the samples and make them available for research. In 2007, the Department of Health agreed to do a better job of informing parents about screening and about the retention of samples in response to privacy concerns among a small but vocal minority.
The MN-AAP has supported recent bills that would protect the newborn screening program and keep the tests as “opt-out” options that are completed unless parents explicitly choose not to have them done.
The Senate version, SF1478 (Schied, DFL-Brooklyn Park) was heard in the Senate Health, Housing and Family Security Committee late in the evening on March 16. MN-AAP President Anne Edwards, M.D., MAFP, testified that while the MN-AAP preferred last year’s version of the bill, the program was so important and members were encouraged to pass the bill. Unfortunately, the motion to pass the bill failed as a result of concerns from committee members that in order to satisfy the concerns of the governor, the bill was too great a sacrifice to the program.
We have until April 7th to pass the bill out of the necessary Senate policy committees and will be working hard to find ways to keep the bill moving forward.
Health Plan PMAP Disclosure
All of MinnesotaCare and most of Medical Assistance and General Assistance Medical Care is now provided through contracts with the state’s managed care plans. The state provides payments to the health plans and the health plans agree to provide care to the public program enrollees. Every year the Department of Human Services enters into negotiations with the health plans to determine what the capitation rate the state will pay to the health plans. Federal law requires that the capitation rate be “actuarially sound” so the health plans receive an increase rate every year.
Legislators are expressing frustration when they try to find out how the health plans are spending that state money because the health plans argue that the payments they make to providers, and the methods they use to determine provider payment rates are proprietary information. Because of this growing frustration Rep Erin Murphy introduced HF 1988. This would require health plans to annually provide to the Commissioner of Human Services information on payments provided to providers, reimbursement increases provided to providers, and the methodology the health plan uses to determine provider reimbursement. Legislators have authority to allocate funding to the managed care plans and health plans have an obligation to show that the money is being used to address access to needed care.
HF 1988 passed the House Health Care and Human Services Policy and Oversight Committee on March 26. The Senate companion bill, SF 1924 (Berglin) will hopefully be heard this week.
PA Changes Moving Forward, APN Bill Appears Dead
Legislation modifying the regulation of physician assistants (PA) is continuing to move forward. SF230 (Higgins) would change the regulation of PAs from registration to licensure. It would also increase the number of PAs a physician can supervise from 2 to 5. SF 320 passed the full Senate by a vote of 55-4 on March 2. The House version (HF 240, Norton) has been included in an omnibus licensing bill that passed the House Health Care and Human Services Policy and Oversight Committee last week. At this point there has been no opposition to this bill.
Legislation proposing changes to advance practice nurse (APN) laws does not seem to be moving forward this year. This issue, arising from the Healthcare Work Force Shortage Task Force, would have eliminated the requirement for a written delegated prescribing protocol for APNs and instead implemented a written collaborative plan. The bill, HF 1668 (Murphy), was drafted by the Minnesota Nurses Association but physicians felt it did not fully represent the recommendations of the task force. The bill was heard in the House Licensing Subcommittee Tuesday March 17. As drafted the bill did not require a written collaboration plan for all APNs, only for those that were not credentialed by a hospital or health plan. The bill also applied to certified registered nurse anesthetists, even though the task force recommendations were not intended for them. Following lengthy discussion, and conflicting amendments, the bill was laid on the table and the committee adjourned.
The Senate companion bill, SF 1532, has not received a hearing so the bill did not meet deadline
Committee Schedules for Next Week
Check www.leg.state.mn.us/leg/sched.asp for the most up-to-date information.
At the Capitol
March 16, 2009
Sara Noznesky, MN-AAP Lobbyist
As the legislature approaches the first committee deadline on March 29th, things are heating up. Budget proposals are starting to fly and policy bills are being heard at a rapid pace.
MN-AAP Testifies on Preventive Dental Bill
MN-AAP Board Member John Andrews, MD testified before the Senate Health and Family Security Committee on Monday March 9th to raise concerns with legislation to mandate that primary care physicians provide preventive dental services as part of a child and teen checkup and also at episodic visits. SF 633 (Berglin, Minneapolis) would require a preventive dental assessment and the application of a fluoride varnish for children on public programs. Dr. Andrews told the committee that pediatricians strongly support dental care as part of overall child health and that the Chapter would support the bill if it were permissive rather than a mandate.
Dr. Andrews also told the committee that while this is a very important aspect of overall health that a growing number of primary care providers are comfortable providing, it does require training beyond their traditional expertise. Not every practice in the state has the capacity to add it at this time. Additionally, there are countless things primary care practitioners are required to do in the brief visit with a patient and their family and each of these two-minute items adds up.
The Minnesota Academy of Family Practice also raised concerns and expressed frustration that dentists in many parts of the state are not serving patients on public programs. They said that the answer is not to mandate the services on to physicians.
DHS already allows MA to reimburse primary care providers to apply varnish. A mandate could result in significant initial cost to the state and a fiscal note is expected on the bill.
The bill passed out of the Health and Family Security Committee on a voice vote and is awaiting hearing in the Senate Finance Committee. The House companion bill HF 984 (Norton, Rochester) is scheduled to be heard in the House Health and Human Services Policy Committee on Tuesday March 17. MN-AAP President Anne Edwards, MD will be meeting with the House author to see if there is a chance for compromise language this coming week.
Booster Seat Legislation Passes Another Hurdle
Legislation to update Minnesota's Child Passenger Safety law passed the
House Public Safety Finance Division on Thursday March 12. HF 267 (Hortman, Brooklyn Park) would expand our current child restraint law beyond car seats for children up to age 8 or 4' 9" tall.
The MN-AAP continues to lobby the bill and members are encouraged to contact their legislators in support of the effort.
The bill is scheduled to be heard in the Senate Finance Committee Thursday morning and will also need to pass the House Finance Committee before being voted upon by the entire House and Senate.
Newborn Screening Bill Being Heard
The Department of Health has coordinated the introduction of the newborn screening bill. Senate File 1478 (Scheid, DF-Brooklyn Park) and House File 1341 (Thissen-DFL, Minneapolis) modifies the newborn screening program specimen retention program, limiting the retention of dried blood spots to two years for the purpose of testing-related research. While the MN-AAP does not support the change, the Governor has indicated this will be the only acceptable compromise he would sign following his veto of last year's bill.
The bill is scheduled for hearings in the Health Policy Committee in the Senate Monday evening and in the House on Tuesday.
Senate Democrats Release Budget Outline
The Senate Democratic Caucus released their outline for solving the budget shortfall on Thursday March 12. Their proposal stresses the need for structural changes to balance the budget for the next four years, not just the two-year period the Governor recommended. They recommend a
7 percent across the board cut to all state agencies, resulting in $5.1 billion in cuts over four years. This budget includes nearly $1 billion in cuts to K-12 education, the largest part of the state's budget. The Governor recommended no cuts to education.
Their budget maintains the Health Care Access Fund as a dedicated fund for health care and helps preserve coverage for low-income Minnesotans.
They do recommend $719 million in cuts to the health and human services areas. Their budget document also calls for $2 billion in new revenues without details on what kind of taxes. When asked, Sen. Tom Baak, chair of the Senate Tax Committee, said he was leaning towards income tax increases, and not expanding the sales tax to clothing or services.
Governor Pawlenty will be releasing supplemental budget recommendations within the next two weeks to incorporate the $1.8 billion of new federal stimulus money.
APN Bill Introduced
Legislation resulting from the Healthcare Work Force Shortage Task Force that met this past summer, to address changes recommend for advance practice nurses (APNs) was introduced this past week. The legislation, drafted by the Minnesota Nurses Association, HF 1668 and authored by Rep. Erin Murphy (DFL-St. Paul) goes beyond what the task force recommended.
Two primary care physicians participated on the task force. The task force recommended removing the requirement for APNs to have a written delegated prescribing protocol as long as the requirement for APNs to have a collaborative plan is strengthened. The task force envisioned that the collaborative plan be written and articulate practice limitations, referral patterns, and APN and physician roles. HF 1668 does not require a collaborative plan for all APNs and does not require that the physician have any say in what is included in the plan.
This bill is scheduled for hearing in the House on Tuesday evening.
Revising Blood Lead Screening Levels
A bill requiring the Minnesota Department of Health to update the guidelines for blood lead level screening is also moving through the legislative process. Current versions of HF419/SF522 specifically mandate certain follow up for screening results over five micrograms of lead per deciliter of blood including venous blood tests at three month intervals and for family members living in the same household under the age of 5.
Current guidelines require follow up if levels exceed ten micrograms per deciliter. Concerns were raised about articulating standards of care in statute and in response the bill's authors are working on amendments to require MDH to establish guidelines for primacy care providers to reflect follow-up for lower levels.
Committee Schedules for Next Week
Check leg.state.mn.us/leg/sched.asp for the most up-to-date information.
Visit our new website at www.mnaap.org for member and practice resources.
Katherine Cairns
Executive Director
Minnesota Chapter of the American Academy of Pediatrics
1043 Grand Ave. #544 St. Paul, MN 55105
651-402-2056 651-699-7798(fax) www.mnaap.org
Peds Day at the Capitol a Huge Success!
Nearly 30 pediatricians attended Peds Day at the Capitol on Tuesday. Thanks to all who attended! Your colleagues met with their elected officials and impressed upon them the importance of ensuring access to health care coverage and the need for an upgraded child passenger safety law (booster seats).
Legislative Activity Slower Than Usual
The Legislature seems to be in a bit of a holding pattern as they wait for updated estimates on the budget shortfall, released March 3rd. With the passage of the federal stimulus package by Congress providing new money to state governments, there is a lot of behind the scenes work going on to determine the exact impact that will have on Minnesota’s budget.
Near the end of last week many hearings at the Capitol were cancelled so Legislators could go on the road and hold “Hearing Sessions” on the Governor’s Budget Proposal throughout the state. For the past two weeks these hearings have been held large turnouts of citizens pleading with legislators not to follow the Governor’s plan to cut the budget.
Most are expecting the next budget forecast on March 3 to show that the state deficit has grown. The current $4.8 billion shortfall could be as high as $7 billion in the new forecast. As the economy continues to struggle and employers announce more layoffs, tax revenues decrease and the need for more safety net funding increases.
Federal Stimulus Provides Opportunities for Health Programs
Congress recently passed the American Recovery and Reinvestment Act of 209 (HR1) to address the nationwide economic crisis. A large portion of the new spending will go to states to assist with health care costs. It is estimated that Minnesota will receive $2.03 billion over the next two years through an increase in the federal Medicaid matching money. Currently in Minnesota the state pays 50% of the Medical Assistance costs and the federal government pays 50%. HR 1 increases the federal match by 6.2%.
HR 1 also provides new money to help providers invest in health information technology (HIT). The Minnesota Department of Health updated the Senate Health and Human Services Finance Division on the Minnesota’s investments in HIT and opportunities for federal funding. The state requires all providers, group purchasers, prescribers and dispensers to have an electronic prescription drug program in place by January 2011. In addition, all healthcare providers and hospitals must have interoperable electronic health records (EHR) in place by 2015. The state has already provided $14.6 million in grants and loans to support adoption of EHR with targeted funds to rural and safety net providers. There have been over $27 million in requests.
According to MDH, the federal stimulus package invests $31 billion in HIT and incentives to encourage doctors and hospitals to use HIT to exchange patient’s health information. No specifics were provided on what portion of the federal stimulus Minnesota would receive. State match would be required for implementation grants. Assistance would be provided to higher education to expand medical health information programs. Physicians using EHR in 2011 can receive up to $44,000 through increased Medicare payments over 5 years and hospitals can receive up to $16 million over 4 years.
Booster Seat Bill Passes More Hurdles
Tom Hellmich, M.D. a pediatrician in Emergency Medicine at Children’s Hospitals and Clinics in the Twin Cities testified Tuesday before the House Public Safety policy committee in support of child passenger safety legislation (HF267/SF99) while participants from Peds Day at the Capitol supported the bill from the audience. Another pediatrician, Mary Rahrick, M.D. from Owatonna, also testified to the need for proper child restraints.
The committee was immensely interested in the physiological differences between children’s ages up to age eight that make children safer in regular seatbelts. It seemed many members may have been interested in only updating the law to age six. The National Highway Transportation Safety Administration states that children should be in booster seats in the back seat from about age four to at least age eight, unless they reach 4’9” tall.
The bill was referred to the House Public Safety Finance Committee where it could be heard as early as next week. Please contact your legislators to let them know the importance of passing this bill. Find out who represents you and how to contact them by visiting: http://www.gis.leg.mn/mapserver/districts/.
Requirement to Provide Basic Dental Exam Introduced
Senator Linda Berglin and Rep. Kim Norton introduced bills (SF633/HF984) since my last update which would require primary care providers to provide primary caries prevention as part of well child and teen visits or at an episodic visit. Primary caries prevention is defined to include, at a minimum, (1) an oral examination, (2) a risk assessment, and (3) the application of fluoride varnish for patients over age one identified as high risk. The bill also requires providers to provide information on caries etiology and prevention, the importance of finding a dental home before age one and a list of dental providers in the local community.
While the MN-AAP supports increasing access to dental care for children, a number of concerns have been raised about the requirements in the bill. The Policy Committee is expected to review the legislation and provide feedback to legislators.
Legislators Consider Increased Phy-Ed in Schools
As legislators look to ways to decrease rates of childhood obesity and increase physical activity, more are turning to the importance of quality physical education in schools. HF439/SF61 authored by Rep. Kim Norton and Sen. Jim Carlson would establish a minimum one-half credit graduation requirement for high school in physical education, beginning with students entering ninth grade in the 2009-1010 school year.
This bill passed the House K-12 Education Policy committee and was sent to the K-12 Education Finance Committee for their consideration.
Dr. John Ratey MD, associate clinical professor of psychiatry at Harvard Medical School with a private practice in Cambridge, Massachusetts flew in to provide testimony in support of the bill. He is the author of Spark: The Revolutionary New Science of Exercise and the Brain. Three time Tour de France winner Greg LeMond also testified in support of the bill. Both spoke about the importance of physical activity for child development (both physical and educational). In committee the bill was amended to allow a limited waiver from the graduation requirement for students participating in qualified athletic activities.
Health Plan Coverage for Autism Treatments
A bill to require private health plans cover services to treat autism spectrum disorders is also moving through the House of Representatives. HF 359 (Norton, DFL-Rochester) would require a health plan to provide coverage for the diagnosis, evaluation, assessment, and medically necessary care of autism spectrum disorders, including but not limited to the following:
(1) intensive behavior therapy, such as applied behavior analysis, intensive early intervention behavior therapy, intensive behavior intervention, and Lovaas therapy;
(2) behavior services, instruction, and management;
(3) speech therapy;
(4) occupational therapy;
(5) physical therapy; and
(6) medications.
(b) Coverage required under this section shall include treatment that is in accordance with an individualized treatment plan prescribed by the insured's treating physician or mental health professional.
(c) A health plan may not refuse to renew or reissue, or otherwise terminate or restrict, coverage of an individual solely because the individual is diagnosed with an autism spectrum disorder.
The bill passed the Commerce Committee this week on a voice vote after an emotional hearing in which parents cited the lack of services covered by health plans. In response, health plans and employers spoke to the high cost of certain treatments compounded by the continued deterioration of the insured market, pointing out that this new mandate would only apply to 27% of the market in Minnesota. The question of cost to state programs caused the bill to be referred to the State Government Finance Committee where a fiscal note will meet up with the bill. The Senate companion, SF312 (Scheid, DFL-Brooklyn Park) has not yet received a hearing.
Practice Environment Issues Emerge
A number of bills that could impact your practice environment are working their way through the legislature.
Physician Assistants
One increases the number of Physician Assistants each physician may supervise by law from two to five and changes PA regulation from registration to licensure. HF240/SF615 (Norton/Higgins) was heard and passed through the full Senate with no opposition.
Safe patient handling
Legislation requiring all clinics that regularly move patients to develop a written safe patient handling plan by July 1, 2010 has passed the Senate Business, Industry, and Jobs Committee with no opposition. SF 594 (Higgins-Minneapolis) states that the plan must have a goal of “ensuring the safe handling of patients by minimizing manual lifting of patients by direct patient care workers and by utilizing safe patient handling equipment” January 1, 2012, The plan shall address:
(1) assessment of risks with regard to patient handling that considers the patient population and environment of care;
(2) the acquisition of an adequate supply of appropriate safe patient handling equipment;
(3) initial and ongoing training of direct patient care workers on the use of this equipment;
(4) procedures to ensure that physical plant modifications and major construction projects are consistent with plan goals; and
(5) periodic evaluations of the safe patient handling plan.
This bill would not require a clinic to purchase any specific equipment or lifts, but only to have a plan in place that was appropriate for the specific needs of that clinic.
Advanced Practice Nurses
Legislation is being drafted by the Minnesota Nurses Association (MNA) to implement the recommendations from the Healthcare Workforce Shortage Task Force. This task force was established by the Legislature last year to review state laws or regulations that may be a burden to allowing practitioners to practice at the top of their license. The recommendations related to advance practice nurses included elimination of the current delegated prescribing requirements that include a written prescribing agreement with a physician, and replacing that with a requirement for a written collaboration plan for nurse practitioners and clinical nurse specialists. The task force report did not include specifics for what should be included in the collaboration plan.
I met with representatives of the MNA last week to review draft legislation on this topic. The plan as drafted by the MNA would include information for patients on whom the nurse would refer to if the needs of the patient exceeded his or her expertise, to what hospital the nurse had privileges, and the type of services the nurse was not qualified to perform. The MN-AAP Policy Committee may review this issue as well.
Committee Schedules for Next Week
Check http://www.leg.state.mn.us/leg/sched.asp for the most up-to-date information.
2008 Legislative Topics
The Minnesota Chapter of American Academy of Pediatrics had 2008 Legislative policy positions on the following topics:
Access - MN-AAP supports universal access and coverage to quality, comprehensive healthcare for all children, adolescents, and pregnant women.
Booster Seats and Primary Seatbelt Enforcement - MN-AAP supports expansion of Minnesota’s child passenger safety law.
Mental Health - MN-AAP supports efforts to increase access to children’s mental health services.
Obesity - MN-AAP supports efforts to prevent childhood obesity.
Early Childhood Education - MN-AAP supports initiatives that support access to early childhood education.
Graduated Drivers License - MN-AAP supports legislation to strengthen Minnesota’s existing Graduated Drivers License law to prevent injury and reduce deaths among young drivers.
Immunizations - MN-AAP opposes legislation that hinders access to vaccines and deters parents from vaccinating their children.
Interoperable Health Record - MN-AAP will support efforts to develop interoperable electronic medical records.
The Chair of the Public Policy Committee is Megan Jennings, MD.
The staff lobbyist for the chapter is Sara Noznesky.
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