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April 23, 2009

Sara Noznesky, MN-AAP Lobbyist

The Legislature shifted gears again this week as Finance committees held their final meetings and quickly passed omnibus spending bills. They have engaged in lengthy floor sessions in order to consider amendments and pass bills. Once budget bills pass both the House and Senate, conference committees will begin. House and Senate Leadership will meet to establish new global targets for each area of spending. At that point, members of the House and Senate will meet to reconcile differences in their bills before reaching a final agreement. Conference Committees are required to complete their work by May 7.  Whether the Governor participates in the discussions (and when he joins) may be an indicator for how long the legislature will be in session. Most insiders expect that the Governor will veto the budget bills as soon as he receives them because the bills are dependent on revenue from tax increases which the Governor opposes.

House Health and Human Services Budget Proposals Released

The House released its proposed Health and Human Services Budget earlier this week. Overall patients and providers did significantly better under the House proposal than under the Governor’s proposal. This is primarily due to the fact that the House proposes to raise $1.5 billion in revenue to help close the budget gap, leaving just over $400 million in cuts necessary in the HHS area. In comparison, the Governor cut $2.2 billion from the HHS budget over the same two-year period.

Following is a brief overview of the finance provisions in Rep. Tom Huntley’s bill, H.F.1362.
The House did not accept the most egregious of the Governor’s recommendations, namely dramatic cuts to eligibility and benefits (including dental, PT, OT and speech language pathology). The House also rejected the Governor’s proposal to eliminate the Health Care Access Fund and merge the revenue into the General Fund. Finally, the House rejected the Governor’s proposal to virtually eliminate the Statewide Health Improvement Plan (public health funding). The House and Senate are expected to try to capture as much federal funding as possible both from the stimulus package and S-CHIP reauthorization package.

The House bill includes the following items:

  • 3% reduction for providers, except primary care providers (family physicians, pediatricians, internists, pediatric, family, adult and geriatric nurse practitioners)  Excludes radiology, lab, rx, medical supplies and primary care – (procedure codes 99201 to 99215) and preventive medicine services (procedure codes 99381 to 99412)
  • 3% ratable reduction for hospitals
  • 5.2% ratable for Mental Health DRG’s 2009, made to hospitals for mental health services within diagnosis-related groups 424 to 432 liability
  • Modified adult dental program rather than elimination of the benefit
  • Managed care withhold to reduce ER admissions ($1.3 million FY10/11)
  • Eliminate patient incentive grants.
  • E-Health Initiative and E-Records loan program–$4 million to get $20 million federal—some funding is retroactive (consistent with federal stimulus)
  • Pharmacy reimbursement cut 1%
  • Funding to create uniform formulary exception and prior auth forms
  • Patient-Centered Decision Making as a study
  • Express lane eligibility for children via free and reduced school lunch applications
  • Presumptive eligibility for children
  • Study on aligning income methodology for eligibility for families and children for MA and MNCare
  • Autism Task Force
  • Reform for Personal Care Assistance eligibility and benefits

Senator Berglin’s Health and Human Services Budget proposal is expected either over the weekend or early next week. Many of the provisions the MN-AAP has expressed concern about are expected to be included in Senator Berglin’s bill including prior authorization for ADHD and mandatory primary caries prevention. Her budget bill is required to cut an additional $200 million (for a total of nearly $600 million) and is expected to be more painful than Rep. Huntley’s bill.

As a result of delays receiving fiscal notes, neither the House nor Senate HHS Budget bills met the legislative deadline and will make an additional procedural committee stop before advancing next week.

Provider Tax Increase

The legislature continues to dance around a potential increase in the provider tax. A sick tax increase had been hinted at as a possible part of the final solution since the beginning of session. Both Representative Huntley and Senator Berglin introduced bills last week to raise the tax.

The House Tax Committee held a hearing on H.F.2315 (Huntley) to raise the tax 1% in order to hear the pros and cons of the provider tax.  After hearing from many provider groups in opposition, including physicians, the bill was laid over without any action.  The House did not include an increase in the provider tax as part of their initial proposal.

When the Senate Tax Committee chair introduced his version of the tax bill on Tuesday without a provider tax increase it looked like the issue was dead for now.  But then on Wednesday, the Senate Tax Committee amended the Senate tax bill to include a placeholder for increasing the provider tax on hospitals and surgical centers only.  The language leaves the amount of the increase blank. The amendment excludes physician services.

Chair of the Senate Tax Committee, Thomas Bakk, DFL-Virginia, has said he does not want to increase the sick tax. However, he wanted to amend the bill as a procedural matter, so that if the negotiations with the Governor do in fact result in an increase the provider tax, the change will be codified in the tax bill instead of the budget bill.

A number of committee members made statements during the committee that they do not want to increase the sick tax, but the fact that they have this “placeholder” language is disconcerting – the Senate has now created an opportunity for that very thing to happen.

Early Childhood Bills Also Move

Early Childhood is an important topic at the capitol this session as well. H.F.2088 (Slawik), the House Early Childhood Omnibus bill passed earlier today. The Senate E-12 Education bill, S.F.1328 (Stumpf), passed before the recess. Differences in the bills will now be worked out in conference committee.

April 17, 2009

Sara Noznesky, MN-AAP Lobbyist

A Short Break for Legislators to Gear-Up for Upcoming Deadlines

Minnesota legislators took a break for Easter and Passover before coming back to face some difficult spending decisions. Lawmakers returned Tuesday and the pace picked up quickly as they faced a Thursday deadline for all finance bills to have made their rounds through the finance divisions. Internal deadlines give legislative finance committees less than a week after that to put the finishing touches on spending bills before sending them to the House and Senate floors for votes.

Tuesday April 7 was the second committee deadline for the Legislature.  With the passage of this deadline bills must be through all non-tax and finance committees in order to be considered alive.  Because of this, all policy committees are now done with their work for the year.  Also, we now have a better idea what bills are alive and what bills are dead.

Now Starts the Budget Work

Minnesota’s Constitution requires the Legislature to adjourn no later than May 18. It is still unclear whether or not the Democrats, who control both the House and the Senate, and Republican Governor Tim Pawlenty can reach agreement on a new state budget. If not, the Governor would have to call a special session before the state budget expires on June 30.

With deadlines for policy committees behind us, the work on passing a balanced budget will now become the main focus of the Legislature.  The most recent budget forecast projects a $6.4 billion deficit for the next two year period. With the help of the federal stimulus money that shortfall has been reduced to $4.6 billion. The Legislature is required to pass a balanced budget before they adjourn.  This can be done through spending cuts, revenue increases, or most likely, a combination of both.

Governor Pawlenty continues to promote a budget that includes no new tax increases and large cuts to the health and human services programs. Because of strings that are attached to the federal stimulus money, he is no longer recommending eligibility cuts for Medical Assistance (MA) or MinnesotaCare.  He is still recommending a 3 percent payment cut to all providers, elimination of most of the optional benefits for adults enrolled in MA, and elimination of the Health Care Access Fund.  The Governor’s recommendations total more than $1 billion in cuts to the health and human services programs over the next two years.

The Senate Democrats have released an outline of their budget recommendations that includes a 7 percent across the board cut to all program areas (including K-12 education) and $2 billion in new revenues. They argue that this is the fairest approach so that no one program takes the brunt of the cuts.  The size of a 7 percent cut to the HHS area totals $719 million in cuts.  When stimulus money is added the 7 percent cut is offset to a 5.9 percent cut, totaling $606 million in 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 4 and 15 percent, protects the Health Care Access Fund, shifts nearly $1 billion into the next biennium, and recommends $1.5 billion in new revenues.  The targets for cuts to the HHS areas total $489 million in cuts, or just less than 5 percent.

The task immediately before legislators is to begin passing omnibus budget bills out of committee.  With cuts ranging from $500 million to over $1 billion needed, the challenges that face them are great.  Because the size of the cuts, discussions are floating about using an increase in the Provider Tax to help solve the problem.  The 2 percent Provider Tax raises over $500 million each year.  Even a ½ percent increase would raise $250 million over the two-year biennium.

Also of interest to physicians is that fact that both the House and the Senate are considering modifying the Governor’s recommendation to cut MA physician payments by 3 percent.  The Governor recommends cutting payments for all outpatient providers y.  Sen. Berglin and Rep. Huntley are recommending cutting every provider 3 percent except for office visits and preventive services provided by primary care providers.  This is an acknowledgement that primary care physicians are under-reimbursed for their services.

Following is an update on the status of a number of policy bills.

Prior Authorization for ADHD Drugs and e-Prescribing

SF 1401 (Berglin) requires the Commissioner of Human Services to establish a utilization review program within the MA program for attention deficit/hyperactivity disorder (ADHD) and attention deficit disorder (ADD) medication and psychotropic medication prescribed to children. The program would require prior authorization for ADHD medication prescribed to children younger than five years of age and a second opinion from a commissioner-approved provider. The bill also requires a physician to receive a second opinion from a commissioner-approved provider for children ages 5 to 18 years of age for ADHD medications that exceed certain dosages.

This is being pursued because a similar program in the state of Washington saved their Medicaid program over $1 million per year in prescription costs.

The MN-AAP is working with the Minnesota Psychiatric Society to express concerns about added prior auth requirements and the impact the bill could have on access to mental health services for children.

The bill also requires the Commissioner of Human Services establish a pilot project to incorporate e-prescribing applications with a clinical information database to reduce errors, increase patient safety, duplication of therapies and reduction in waste.  The commissioner shall ensure that each provider identified has the ability through e-prescribing software to receive the following:
(1) a patient’s specific medication history for the last 100 days;
(2) the preferred drug list and formulary verification;
(3) prescription details; and
(4) drug interaction alerts.

The commissioner shall evaluate the project in terms of the number of prescriptions written by the providers participating in the demonstration project and report to the Legislature by March 15, 2011.

Health Care Homes Required for Chronic Disease

To ensure the use of health care homes, legislation is moving in the Senate that would require MA patients with chronic or complex disease to select a primary care clinic with clinicians who have been certified as health care homes.  SF 1474 (Berglin) would implement this requirement only if there are two or more primary care clinics with clinicians who have been certified as health care homes available to the enrollee.

This bill is awaiting action in the Senate Finance Committee and could be included in the omnibus HHS budget bill.

Newborn Screening Changes Now in Omnibus Policy Bill

Legislation designed to allow Minnesota’s newborn screening program to continue is moving forward in a compromise version that still has many opponents. Last year Governor Pawlenty vetoed needed legislation because of concerns with privacy advocates over the ongoing use of the gathered blood spots without parent’s consent.  The compromise language (found in HF1341, Thissen) requires that all bloodspots be destroyed within 25 months unless the Department of Health has parental consent to keep the specimens longer.

The Senate companion bill to HF 1341 did not make the committee deadline because key Senators did not support the compromise that the Governor proposed.  They believe that it will severely threaten our role as a pro-medical research state.  To keep the bill alive the House language has been amended into a separate bill, HF 1760.  This bill has met deadline in both bodies.

Booster Seats and Primary Seatbelt Penalty

Two bills to strengthen our traffic safety laws to protect vehicle passengers are still moving through the legislative process. Child passenger safety bill has passed the Senate floor and met the policy committee deadline in the House. The bill, SF 99 (Carlson), would require children up to 8 years old and 4 feet 9 inches tall to use proper child restraint systems, such as booster seats. The bill is scheduled for a hearing Monday morning in the full House Finance Committee.

The seatbelt bill SF 42 (Murphy) would make not wearing a seat belt a primary offense, which would allow officers to stop and ticket motorists for not wearing their seat belts.  Currently, drivers can be ticketed for not wearing a seat belt only if they are stopped for another violation. This bill is also still alive in both the House and the Senate.  It is awaiting action is the finance committees of both bodies.

Dental Caries Prevention

A bill related to primary care physicians performing fluoride varnish and dental exams during Child and Teen Check Ups met the policy deadline. The Senate version of the bill (SF633, Berglin) requires that primary care providers do an inspection of the oral cavity and apply a fluoride varnish as part of any child and teen checkup. Pediatricians and family practice doctors raised concerns about this being a mandate. If the preventive check is done, the primary provider must inform the patient of the etiology of dental caries, and the importance of a dental home, and advise the parent that they contact the HMO or DHS in order to secure an appointment. The Senate passed the bill with the mandate in place to the floor—although it was referred back to the finance committee for an anticipated fiscal note. It is unclear whether the bill will be included in the Senate budget package due to an anticipated fiscal note.   The House language (HF984, Norton) is permissive and has no fiscal note therefore it passed out of the House policy and finance committees.

Prior Authorization and Uniform Formulary

This bill, initiated by St. Mary’s Duluth Clinic, requires the commissioner of health, in consultation with the Minnesota Administrative Uniformity Committee, to develop a uniform prior authorization and formulary exception form that allows health care providers to request exceptions from group purchaser formularies, including Part D plans, using a uniform form, within six weeks from the enactment date or July 1, 2009, which ever is later.  Effective January 1, 2011, the uniform prior authorization and formulary exception form must be accessible by health care providers, and accepted and processed by group purchasers, electronically through a secure Internet site.  Electronic transmissions from providers would be required by January 1, 2011.

The House also passed a similar version of this bill and is working with the Council on Health Plans to come up with a form that can be implemented this spring.

MA Coverage Elimination for Ineffective Preventive Services

SF 1442 /HF 1783 eliminates benefit coverage under state health care programs for those clinical preventive services that the U.S. Preventive Services Task Force has recommended against providing to an asymptomatic patient, or has been graded by the task force as a “D.” Lead level testing for pregnant and women is specifically excluded and would remain a covered benefit. This bill is yet another attempt to gain fiscal savings.  The bill has met policy deadlines.

Health Care Homes Outreach Requirement

SF 1474  requires the state health plan enrollees who have complex medical conditions to select a primary clinic with clinicians as certified health care homes, if there are two or more primary care clinics with clinicians who have been certified as health care homes available to the enrollee. The MN-AAP is reviewing the bill to ensure that access would not be restricted for children based on the availability of health care homes. It remains unclear whether this will result in any savings to the state, but it has met deadline and is being considered for inclusion in the Omnibus HHS Finance bills.

Committee Schedules for Next Week

Check http://www.leg.state.mn.us/leg/sched.asp for the most up-to-date information.

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.

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.

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