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April 30, 2010

House Moves Omnibus HHS Bill and Senate To Act on Monday

The House HHS bill that passed out of the Finance committee this week reduces spending for HHS programs by $18.4 million in FY10 and $147.9 million in FY11. Although the bill is not available, the Senate released its spreadsheet, which reduces spending by $6.69 million in FY10 and $113.4 million in FY11.  Both bills provide significant relief, compared to a $346 million reduction proposed by the Governor and the GAMC bill that passed earlier.  The House and Senate cover the GAMC population (under 75% of FPG) under Medical Assistance (MA) through the early opt-in allowed under the federal reform and also maintain coverage for single adults in MNCare.

The bills differ in how they generate revenue to fund this expansion.  The House has an HMO surcharge, 7.5% ratable reduction for hospitals and makes other reductions for providers. Originally, the surcharge was 7%, but was increased to generate revenue to exempt Children’s Hospitals and Gillette from the ratable, as well increase Gillette’s outpatient rates. The House also makes other cuts to providers.  The Senate increases the hospital surcharge to 2.63% July 1, 2010 and 2.3% January 1, 2011.  The HMO and nursing home surcharge is also increased to generate revenue along with other reductions to HMO’s and providers.  There is a 3% rate reduction for PMAP and the 10% rate reduction for MNCare adults over 75% of income that generate $42 million and $14.7 million respectively that cannot be passed on to providers.  In addition, the Senate delays hospital rebasing until 2013.  Neither bill cuts the MERC funding as proposed by the Governor.  The House bill made deep cuts in mental health services for both adults and children, while leaving the state-operated services untouched.  Minnesota NAMI lead the charge against the deep cuts, especially for children’s mental health, and it appears that there will be an amendment in Ways and Means to restore some of the funding.

The House bill will be in Way’s and Means on Monday and could be on the floor Monday or Tuesday.

House HHS HF 2614

Article 2

  • Increases surcharge on HMO’s to 2.5% effective July 1, 2011 for fee for service and January 1, 2012 for PMAP.
  • Ratably reduces payments for inpatient admissions 7.5% beginning June 1, 2010. Exempts Children’s Hospitals and Gillette from ratable.
  • Increases pharmacy dispensing fee for sole-community pharmacies from $3.65 to $4.25.
  • Sets the acquisition price of drugs of Average wholesale price (AWP) minus 12.5% or wholesale acquisition costs (WAC) plus 5.0%, whichever is lower. Current law is AWP minus 15%.  Also sets the antihemophilic factor drugs at AWP minus 28.12 or WAC minus 13.76%.  Current law is AWP minus 30%.
  • Oral interpreters services are covered only if the interpreter is on the registry or roster established by the commissioner, effective July 1, 2010.
  • Allows commissioner to purchase medical supplies with competitive bidding and negotiating.
  • Sets income level for single adults to 75% of FPG retroactively to April 1, 2010 for MA.  Funds with HCAF.
  • Requires authorization for PT (80 unites of any approved CPT code: 20 modality sessions; and 3 evaluations/reevaluations) OT (120 units and 1 evaluation) and Speech Language (50 treatment and 1 evaluation) that exceeds certain units of treatment, modalities, and evaluations and re-evaluations.  Eliminates special maintenance therapy.  The Governor recommended elimination.
  • Amends current dental service coverage and partially restores funding for critical access.  The Governor recommended elimination.
  • Pays traditional licensed midwives up to 100% of the physician rate for the same services.
  • Reduces non-emergency co-payments for ER’s from $6 to $3.50 and increases the monthly maximum from  $7 to $12.
  • Establishes a payment reform demonstration project for providers serving an identified group of patients who are enrolled in a state health care program and are high utilizers or have characteristics that put them at risk of being high utilizers. The goal is to reduce hospitalizations, ER visits, high cost medications, specialty services, or nursing home or long term care. Projects serving patients with chronic medical conditions or complex medical needs that are complicated by a physical disability, serious mental illness, or serious socio-economic factors, are given priority.  Requires that project reduces total cost of care.
  • Intensive Management Care Program is established for enrollees over 18 in the top 5% of costs.  Requires the program to reduce costs by 20%.
  • Increases rates to HMOS after August 1, 2010 by 1.4%.
  • Reduces payments made to HMO’s by 1% on January 1, 2011.
  • Exempts rehab therapy services from the 5% ratable reduction in current law effective July 1, 2010.  Section 32, reduces payment by 3% and classifies them as basic care services.
  • Physicians and professional services
    • Reduces by 3% effective July 1, 2010.  Does not apply to preventive medicine visits provided by primary care providers that includes pediatricians.  Makes the payment reduction effective for HMO’s October 1, 2010.
    • Increases payments to HealthPartners clinics by15%.
    • Payments for services can’t exceed Medicare.
    • Increases fee for service payments by 7% effective January 1, 2011
  • Prohibits the Commissioner from modifiying state programs before July 1, 2014 under financial management statute.
  • Requires MnCare to offer supplemental hospital coverage to pay for costs over $10,000 and must state that adults without children in MnCare are responsible for the amount over $10,000.
  • Makes changes to critical access dental providers that limit the number of eligible providers.
  • Includes Medication therapy management as a covered service under GAMC between April 1 and May 31.
  • CCD’s clarifies that enrollees should choose a provider when there is more than one, what is within 25 miles of their home.  Changes the schedule of quarterly payments. Non CCD hospitals that transfer patients to receive a higher level of care are not reimbursed by the CCD and are only eligible for the charity care pool.  Add ambulance service to charity care pool; if transfer is more than 25 miles form the health care facility receiving the patient.  Extends charity care pool to December 31, 2010.

Article 5, Miscellaneous

Oral Cancer Chemotherapy Parity—requires HMO’s and insurance policies to have parity for the purpose of out of pocket costs for intravenous and oral chemo therapy agents. Effective August 1, 2010.

Autism Spectrum Disorder Coverage (page 76)
Creates a new mandate for specific services for autism spectrum disorder.  Specifies coverage, treatment providers, and services.  Exempts the State Employee Plan (SEGIP) and state health plans due to the fiscal note, however the new language requires that plans maintain their current level of coverage.  Some of the plans cover some of these services and some don’t.  Several families of autistic children testified in favor of the bill. The Somali community expressed concern that they were being discriminated as they won’t have coverage under MA or MnCare, or SEGIP as they are exempt—except for the plans that currently provide the coverage.  Appropriates $50,000 to monitor the gaps in level of service provided in state health programs, SEGIP, and private health plans.

HMO Reporting
Adds amounts paid to contractors, subcontractors, and other entities for the purpose of managing provider utilization or distributing provider payments to the current reporting requirement.

Coverage for Private Duty Nursing Services
Requires a health plan to pay for private duty nursing services at the same level as Medical Assistance.  Allows for cost sharing at inpatient hospital stay.  Effective July 1, 2010.

Advisory Group on State Operated Services
Establishes an advisory group to make recommendations on the transformation of state services for individuals with mental illness and developmental disabilities to access quality care across the state.  The bill does not make the SOS reductions proposed by the Governor.

Cambridge State Operated Services (SOS)
Allows Cambridge to reorganized into two 16 bed facilities, one for DD and one for MH, with the remaining beds converted to transitional intensive foster homes.

Pilot Projects for Chemical Dependency
Allows the DHS to approve and implement pilot projects that were authorized last session to provide alternatives to and enhance coordination of delivery of chemical health services. Projects must be revenue neutral.

Office of Inspector General
Creates an office to enhance anti-fraud activities.

Article 6, Department of Health

HMO Administrative and Investment Income Reporting
Establishes reporting requirements for HMO’s and establishes an advisory group to develop cost reporting recommendations.

E Health Records and Health Information Exchange (page 95)

  • Ensure all information follows the patient across the full continuum of care.
  • Prevent fragmentation of health information that can occur when there is lack of interoperability or cooperation between health information exchange providers.
  • Ensures that organizations are adhering to nationally recognized standards.
  • Ensure patient privacy and security.
  • Ensure that that MN infrastructure is in place by 2010 to allow Minnesota providers and hospitals to achieve meaningful use.
  • Establishes criteria, oversight and fees.

Birth Center Licensing (page 109)
Adds birth centers as an essential community provider. Establishes licensure for birth centers using the Commission for the Accreditation of Birth Centers (CABC) standards.  Includes other professionals in reviewing birth center outcomes including representative of the College of OB/GYM, American Academy of Pediatrics, the Minnesota Hospital Association, and the Minnesota Ambulance Association to the list of those evaluating the quality of care and outcomes for service providing in birth centers.

Lead Levels
Allows the Commissioner of Health to revise clinical and case management guidelines by January 1, 2011, to reflect new recommendations for protective action and follow-up services for child blood lead levels that exceed 5 micrograms of lead per deciliter of blood.  Requires the commissioner to consult with a statewide organization representing physicians, the public health department of Minneapolis and other public health departments, and nonprofits with expertise in lead abatement. The revised new guidelines must be implemented to the extent possible with available resources.  Appropriates $79,000 to revise the guidelines.

Article 7, Health Care Reform

Baskets of Care/Accountable Care Organizations (ACO)
Requires DHS to establish uniform definitions for the total cost of provide all necessary services to a patient through and ACO as specified in the federal reform bill.  Permits an ACO to establish package pricing for the baskets of care currently in statute (coronary artery disease and heart disease, diabetes, asthma and depression).  Beginning July 1, 2012 prohibits and ACO from varying the payment amount that the provider or organization accepts for full payment for services.  Requires quality measurements for ACO’s by June 30, 2012, and published comparative price and quality information on the total cost of care by January 1, 2013.

Coordinated Medical Homes (page 119)
Requires DHS to provide MA coverage of medical homes for eligible individuals with chronic conditions who select a designated provider, a team of health care professionals, or a health teams as the individual’s home in compliance with the federal reform bill.  To be eligible, the individual must have two chronic conditions, one chronic condition and be at risk of developing a second, or one serious and persistent mental illness.  Defines what services must be included and to the extent possible that they are consistent with the requirements and payments for health care homes under MA.  Allows the commissioner to modify the requirements to be consistent with the federal law.

Federal Health Care Reform Demonstration Project
Requires the DHS to apply for grants in the federal reform including:

  • Evaluation of integrated care around hospitalization. (section 2704)
  • MA global payment system (Section 2705)
  • Pediatric ACO (2706)
  • MA emergency psychiatrist (Section 3707) and
  • Grants to provide incentives for prevention of chronic diseases (section 4108).

Health Care Reform Task Force
Requires the Governor to establish a task force to advise and assist in the implementation of the federal health care reform bill.  Requires a report on recommendations by December 15, 2010.

Federal Health Care Exchange
Requires state to apply for one or more planning grants relating to establishing the exchange. Also requires the state to consider whether the exchange should be established before the federal deadline of January 1, 2014.

Appropriations

  • Reduces adult and children’s mental health grants by $15 million. Also reduces payments to counties for these services.  Some are done on one time basis and as mentioned earlier may be restored in Ways and Means.
  • Provides $8.5 million in FY12 and 13 for SHIP grants. These are one time additions.
  • $2.5 million for community clinics and $2.5 million for FQHC’s with priority to medical underserved areas of the state not served by a CCD.
  • Reduces CD fund payments, moves the CD Fund cash balance to the general fund and makes changes to CD fund payments based on new payment methodology, for providers with above average rates. Caps payments at 160% of average.

Senate HHS Bill Ready Monday

The Senate committee released its spread sheet this week, but no bill.  Based on the spread sheet, the Senate cuts $113 million for the FY10/11 biennium.

The following are included:

  • Expands MA to single adults under 75% of poverty ($115 million) Uses HACF
  • Hospital Surcharge of 2.63% July 1, 2010 and 2.3% January 1, 2011, by $43 million. Hospitals receive roughly $35 million back in various adjustments to their MA rates.
  • Delays hospital rebasing through January 1, 2013.  Cuts $9.2 million in FY11 and $94 million in FY12/13.
  •  Does not cut critical access to the extent proposed by the Governor.
  • Funds asthma demonstration project expansion.
  • Does not eliminate adult rehab services (PT, OT, Speech language)
  • Increases managed care withhold
  • Enacts HMO Surcharge
  • Reduces payments to HMO’s by 10% for MnCare single adults above 75% of poverty and non administration MA reduction of 3% effective 7/1/2010 that can not be passed on to providers.
  • Partially funds State Operated Service Increase
  • Increases pharmacy board budget—to fund NASPER.
  • Does not cut MERC
  • Does not eliminate coverage for single adults in MnCare
  • Does not eliminate rural DRG Add on.
  • Does not cut state operated services.
March 30, 2010

First Round of Budget Cuts Moves to Governor Before Passover/Easter Break
(HF 1671 / SF 3223)

The conference committee report for HF 1671 passed both the Senate and House floors on Monday March 29, just prior to the Legislature beginning its Passover/Easter break.  This bill is the first of three bills designed to close the state’s $994 million budget deficit. The bill includes net reductions in spending of $313 million in FYs 2010-2011 and $413 million in FYs 2012-2013.  It is on its way to the Governor for his signature.

The supplemental budget bill includes reductions in agency budgets for higher education, economic development, natural resources, agriculture, veterans, public safety, energy, transportation and the legislative, judicial, and executive branches of government.  It is round one of the House and Senate’s budget strategy. The E-12 Education bill and Health and Human Services will be considered after the Passover/Easter Break, which began Monday evening. Legislators will return for work on April 6th.

The HHS finance chairs are getting the details regarding what federal match might be available to soften the proposed cuts.  The HHS target assumes that there will be at least $408 million in extra federal matching funding for Medical Assistance (MA).  With this additional federal money they will be expected to still cut an additional $155 million.

At issue is whether the new money from the federal health care reform bill—that includes a provision for Minnesota to adopt immediate expansion of MA for adults without children earning up to 133% of federal poverty level—will and can be used to “fix” the GAMC bill that was just signed, and to what extent it can reduce other proposed reductions by the Governor.  Recall that the Governor’s budget proposed sharp reductions for physician payments, hospital payments, and Medical Education and Research (MERC) funding.  The House HHS budget bills are expected to be released to the public on Tuesday, April 6.  The Senate is moving slower and will hold a hearing on the federal reform on Tuesday April 6th.

GAMC Signed By Governor Chapter 200

The compromise bill for a stripped down GAMC bill passed both bodies and was signed by Governor Pawlenty on March 26th.  On final passage, the bills had only 12 no votes in both the House and Senate.  All of those no votes came from Democrats who believed that this bill left very little leverage for legislative leaders to negotiate a better bill with the Governor using the new federal match for this population included in the Health Care Reform Bill.

Highlights of the proposal include:

  • It preserves GAMC in its current form until June 1 with provider payments cut by 63 percent.
  • Beginning June 1 the program would operate through a “coordinated care delivery system” (CCDS).  The 17 hospitals representing about 70% GAMC caseload and providing geographic access would be eligible to be CCDS.
  • The CCDS are required to coordinate and provide all necessary care for a set fee.
  • Outpatient/physician services other than those provided by staff physicians of CCDS are not covered unless they contract with a CCDS.
  • From June 1 to November 30, 2010, hospitals that are not a CCDS will share a $20 million uncompensated care pool to pay for GAMC patients who need medical services. After November 30, 2010, services are available only through a CCDS.
  • Beginning December 1, 2010, other hospitals may join but the pool of money is limited.
  • Effective June 1, 2010, a prescription drug pool will reimburse pharmacies and other providers for prescription drugs. Prescription drug costs will continue to be covered outside of a CCDS will be required to pay in the aggregate 20% of the state’s appropriation for the prescription drug pool.  Each CCDS assessment must be in proportion to the system’s share of total funding provided by the state for CCDS.
  • It provides rapid access to psychiatric consultation for low-income populations.
  • It establishes a process to make recommendations on appropriate drugs and doses of ADD/ADHD and psychotropic medication for children and adolescents with the goal of reducing the use of medication.  The commission will track utilization and other practices and beginning July 1, 2011, may require psychiatric consultations and prior authorization if a provider prescribes an atypical dose or medication. Also provides some financial penalties.

Birth Centers HF 3046 and SF2702

This bill establishing licensure for birth centers is traveling as an independent bill and will likely be included in both HHS omnibus bills.  At the most recent hearings in both bodies, an amendment that requires the commissioner of health, in consultation with DHS and members of the birth centers to evaluate the quality of care and outcomes for services provided by licensed birth centers.  Following the hearing in the House, Rep. Ruud agreed to include a member of the American Academy of Pediatrics as part of an amendment to include providers other than representatives of birth centers to assist the commissioner in tracking outcomes for birth centers.  The bill allows medical assistance to reimburse only licensed practitioners for labor and delivery.  Lay midwives are not licensed in this state.  HMOs would be required to reimburse birth centers under this bill as well.  The Senate is carrying a fiscal savings in the Omnibus bill for the anticipated reduction in reimbursement for normal deliveries.

ADD/ADHD Diagnosis for Special Education – May Be Dead (HF 2995 / SF 2708)

It appears that a fiscal note from the Education Committee may permanently table the bill initiated by the Minnesota Social Workers Association to allow social workers, counselors and marriage and family therapists to make a diagnosis ADD and ADHD for the purposes of getting an independent medical plan for kids in school. There was discussion by the special education community that adding practitioners who could diagnose ADD/ADHD might lead to more referrals for special education services without providing the schools more money.  Special education funding is currently capped and any increase in ADD/ADHD services would result in reduced funding for other categories.  The education community argued that this was another unfunded mandate for which schools would have to pick up the costs.  Licensed psychologists who opposed allowing marriage and family therapists the authority to make this diagnosis without special training opposed the bill.

Compromise Primary Caries Bill Moves Forward SF633 / HF984

The bill that passed last year in the House that encouraged physicians to perform primary caries prevention at the time of the child and teen check up was heard again in House Finance Committee and sent back to the floor.  In addition, the Senate author adopted the House language that dropped the mandate for screening and defines that prevention services include a visual exam of the mouth without using probes or other dental equipment, risk assessment using AAP and pediatric dentistry; and a fluoride varnish beginning at age 1 to those assessed by the provider of being high risk for decay.  Physicians are already allowed to be reimbursed for these services. If a physician provides these services they must provide and document in the medical record that the family received information about preventing dental disease and the importance of finding a dental home.

Mandatory Reporting – Pregnant Women (SF 2695 / HF 3059)

The bill that amends the current law when a provider must report a pregnant women who they suspect are abusing chemicals if they are receiving a comprehensive set of prenatal services has passed the Senate floor and is awaiting final action in the House. The bill is designed to loosen the requirement that a health care worker immediately report to the local welfare agency if the person knows or has reason to believe that a pregnant woman has used a controlled substance for a nonmedical purpose or excessively used alcohol during her pregnancy. The Minneapolis Public Health Department experienced a “chilling” effect on women willing to access prenatal services due to the reporting requirement.  The new bill would exempt a professional from reporting if the professional knows or has reason to believe the woman is seeking or receiving prenatal care from a health care professional.

Lead Levels in Children (HF419 / SF 522)

Both of these bills address minimum blood lead levels.  They both have passed out of policy committees in differing forms and are moving through the process.

The House bill directs the Commissioner of Health to revise clinical and case management guidelines by January 1, 2011, to reflect new recommendations for protective action and follow-up services for child blood lead levels that exceed 5 micrograms of lead per deciliter of blood. It requires the new guidelines to be implemented to the extent possible with available resources.

The Senate bill amends the Lead Poisoning Prevention Act by also reducing the lead level to 5 micrograms of lead per deciliter of blood, but it uses the new dose in prioritizing lead abatement projects.

BMP Adopts Lyme Position; Legislation Pulled (SF 1631 / HF 2597)

Legislation to limit the Board of Medical Practice (BMP) authority to discipline physicians related to the treatment of Lyme disease has been pulled from consideration by the authors because of action taken by the BMP at its March 13 Board meeting.  At that meeting the BMP agreed to a voluntary moratorium on action related to the treatment of chronic Lyme disease, for a period of no more than 5 years.  While this is not an ideal situation, this is a much better outcome than the passage of legislation that would have created a very bad precedent for the Legislature telling the BMP how to act.

The resolution adopted by the BMP follows:

1. Whereas: The science regarding the presumptive diagnosis “chronic Lyme disease” and the long term prescription and administration of antibiotic therapy for its treatment is unsettled.
2. Whereas: The Minnesota Board of Medical Practice has never investigated, disciplined, or taken any other action against any practitioner solely on that basis.
3. Whereas: The Minnesota Board of Medical Practice has never received any complaints solely on that basis.
4. Whereas: Patients, some physicians, and the public are seeking guidance on this issue.

Therefore, in the interest of allowing time for science to resolve this issue:

1. The Minnesota Board of Medical Practice voluntarily will engage in a moratorium for a time period not to exceed five years, or the time at which double-blind, peer reviewed studies have resolved the issues, whichever is first, on the investigation, disciplining, or issuance of Corrective Action Agreements based solely on long term prescription or administration of antibiotic therapy for “chronic Lyme disease,” except in the event of a complaint lodged by a patient or by a conservator, parent or guardian on the patient’s behalf for this specific use of antibiotic therapy.
2. Will publicize this voluntary action on its website.
3. Will educate its staff, medical coordinators, and members regarding this voluntary action.
4. Will diligently seek the results of double-blind, peer reviewed scientific studies that address this issue.
5. At the end of the five year period, in the absence of such scientific studies which bring a conclusion to the issue of the legitimacy of this diagnosis and treatment, the Board will re-examine this issue based on evidence available at the time.

March 19, 2010

GAMC Agreement Moving Fast

Governor Tim Pawlenty and DFL legislative leaders finally reached a deal to maintain the GAMC program. The “deal” fell apart several times during the week but a final legislative language was released to the public on Wednesday March 10, and the bill was heard and passed in both the House and Senate health finance committees on Thursday March 11.  Both bills are expected to be acted on by the full House and Senate by the week of March 15.

Most testifiers, including representatives of hospitals and the Minnesota Medical Association, supported the proposal under the rationale that some kind of program was better than no program.  MMA told committee members that this bill should not be billed as “reform” but as a cut to providers.  In addition, several testifiers told legislators that they must consider these cuts in balancing the budget.

The good news is that the deal continues the GAMC program beyond the scheduled elimination date of April 1, 2010.  The bad news is that it is significantly scaled back.  What has been an approximately $500 million per year program is now funded at $164 million. What had been a program that provided all services through inpatient and outpatient providers is now a program where services will only be reimbursed through hospital-based Coordinated Care Organizations (CCOs).

Effective, June 1, 2010 the Commissioner of Human Services may contract with the 17 hospitals that provide the most GAMC care.  Any hospital who becomes a CCO will be required to provide all services for GAMC patients, both inpatient and outpatient.  They will be paid a capitation fee to provide those services and they will be expected to accept all risk for the patient’s care.

Highlights of the proposal include:

  • Preserves GAMC in its current form until June 1 with provider payments cut by 63 percent.
  • Beginning June 1 the program would operate through a “coordinated care organization” (CCO).  The 17 hospitals representing about 70% GAMC caseload and providing geographic access would be eligible to be CCOs.
  • The CCOs are required to coordinate and provide all necessary care for a set fee.
  • Outpatient/physician services other than those provided by staff physicians of CCOs are not covered unless they contract with a CCO.
  • From June 1 to November 30, 2010, hospitals that are not CCOs will share a $20 million uncompensated care pool to pay for GAMC patients who need medical services. After November 30, 2010, services are available only through a CCO.
  • Beginning December 1, 2010, other hospitals may join but the pool of money is limited.
  • Effective June 1, 2010, a prescription drug pool will reimburse pharmacies and other providers for prescription drugs. Prescription drug costs will continue to be covered outside of a CCO.  CCOs will be required to pay in the aggregate 20% of the state’s appropriation for the prescription drug pool.  Each CCO assessment must be in proportion to the system’s share of total funding provided by the state for CCDs.

The exact hospitals included in the 17 is not completely clear but they include Hennepin County Medical Center, Regions Hospital, University of Minnesota Medical Center-Fairview, Immanuel St. Josephs, North Memorial, Abbott Northwestern, St. Cloud Hospital, Mercy Hospital, Fairview Ridges, United Hospital, St. Mary’s Duluth Clinic, Mayo Psychiatric  Hospital, St, Mary’s Region Health Center-Detroit Lakes, Mercy Hospital-Carlton, North County-Bemidji, Mahnomen Hospital, and Rice Memorial-Willmar.

Also added back to the bill is the section that requires the commissioner, in consultation with the Drug Review Board and Pediatric mental health providers, to identify recommended dose ranges for atypical antipsychotic drugs and drugs used for ADD/ADHD based on available medical, clinical and safety data research.  The Commissioner is required to periodically review the list of medications and pediatric dose ranges and update the medications and does listed as needed after consulting the Drug Utilization Review Board.

In addition, situations where a collaborative psychiatric consultation and prior authorization should be required before the initiation or continuation of drug therapy in pediatric patients, including, but not limited to high-does regimen, off-label use of  prescription medication, a patient’s young age, and lack of coordination among multiple prescribing providers must be identified.

DHS will also track prescriptive practices and uses of psychotropic medications in children with the goal of reducing the use of medications, where appropriate.  Effective July 1, 2011, the commissioner must require prior authorization and a collaborative psychiatric consultation before an atypical antipsychotic or ADD/ADHD drug meeting the criteria established under this provision is eligible for payment.  The collaborative psychiatric consultation must be completed before the identified medications are eligible for payment, unless: the patient has already been stabilized on the medication regimen; or the prescriber indicates the child is in crisis.  In this case the consultative evaluation must be completed within 90 days.

Dr. Schiff has indicated that Minnesota has a good track record in this area—and the medical community has not been identified as a state that over subscribes medication for
children.  This provision has been strongly supported by NAMI.

ADD/ADHD Diagnosis for Special Education

The ADD/ADHD (H.F. 2995/S.F. 2708) bill was considered in the Education policy Committees and there were several amendments considered.  This bill is being pursued by the Minnesota Social Workers Association to allow social workers to make a diagnosis of ADD and ADHD for the purposes of getting an independent medical plan for kids in school. There was discussion by the special education community that adding practitioners who could diagnose ADD/ADHD might lead to more referrals for special education services without providing the schools more money for this.  Senator Solon wanted to pursue her amendment to add educational requirements for the social workers.

The bill passed out of the House Education Committee limiting the new authority to diagnose ADD/ADHD to social workers and counselors.  One version of the bill also allowed Marriage and Family Therapists to do this but they were deleted from the proposal.  An amendment that would have required these two groups to be allowed to diagnose ADD/ADHD only if  the practitioner “successfully completed course work and supervised clinical experience in administering, interpreting, and integrating psychometric testing for the purpose of differential diagnosis,” failed after testimony from the school social workers opposed it as well as the bill author.  As the bill now stands in the house, social workers and counselors will be added as practitioners who can make the diagnosis.

Primary Caries SF633/HF984

The bill that passed last year in the House that encouraged physicians to perform primary caries prevention at the time of the child and teen check up was acted on in the Senate.  The Senate author adopted last year’s House language which dropped the mandate for screening and defines prevention services to include a visual exam of the mouth without using probes or other dental equipment, risk assessment using an AAP and Pediatric Dentistry tool, and a fluoride varnish beginning at age 1 to those assessed by the provider of being high risk for decay.  Pediatricians are already reimbursed for these services. If a pediatrician provides these services they must provide and document in the medical record that the family received information about preventing dental disease and the importance of finding a dental home.

Governor Recommends Drastic Cuts to Medical Education

The Governor’s proposed supplemental budget contains a $55 million reduction to the Medical Education and Research Cost (MERC) fund.  This is the main state funding program that supports a portion of the costs of the required clinical training for health
professional students and residents.  This 83% reduction will affect the University as well as our partner sites – hospitals, clinics, and pharmacies throughout Minnesota — where clinical training occurs.

MERC covers clinical training of medical students and residents, dental students and residents, pharmacy students and residents, advanced practice nursing students, physician assistant students, and chiropractic students.   The purpose of the fund is to compensate hospitals, clinics, and other health care providers for a portion of the costs of clinical training.  MERC is administered by the Department of Health.  MERC funds can only go to organizations that provide clinical training to students and residents from one of the state’s Sponsoring Institutions (e.g. U of M, Mayo, Hennepin, St. Scholastica, state colleges).  In essence, the money follows the students and goes to hospitals, clinics, and pharmacies.

MERC funds go both to medical schools and to residency training sites.  The Governor recommends cutting the dedicated payments to the University of Minnesota (Academic Health Center and Dental School) and University of Minnesota Medical Center, Fairview    ( 32.5 percent cut to $5.35 million in 2009).  He also recommends cutting the general distribution to eligible hospitals, clinics, pharmacies, and other providers based on their proportion of medical assistance and general assistance medical care (87.5 percent cut to $60.7 million in 2009).

Biggest impact of the residency cuts are (estimated in millions):

Abbott Northwestern $  2.1
Children’s Minneapolis $  3.6
Children’s St Paul $  1.5
UMMC, Fairview $  5.4
Other Fairview units $  2.1
Gillette Children’s $    .9
Health East $  2.8
HCMC $  7.5
Hennepin Faculty Assoc $    .9
St. Joseph’s $    .8
Mayo, St. Mary’s & Methodist $  3.2
Mercy Hospital $  1.1
North Country Regional $    .8
North Memorial $  2.4
Park Nicollet Memorial $  1.0
Regions Hospital $  3.7
St Cloud Hospital $  1.8
St Luke’s Duluth $    .6
St Mary’s Duluth $  1.1
United $  1.9
Unity $    .8

 

Committee Deadlines and Budget Resolution

As the second committee deadlines approaches, legislators are rushing to get policy bills passed by, Friday, March 19th.   Bills must be through all policy committees by Friday to remain alive for the year, unless a special vote is taken in the rules committee.   March 29th is the third deadline, where finance bills are to have cleared their finance divisions.  Leadership indicated that they may waive the committee deadline for health and human services and K-12 until there is action by the federal government on the FMAP extension and health care reform.  Legislators will be taking most of the Passover/Easter week off.
The House Budget Resolution was announced and cuts of $155 million out of HHS assuming $408 for FMAP and $147 for GAMC.  If FMAP does not come through and GAMC does not pass, the HHS target is down $710 million. This does not include any assumptions for additional funding if federal health reform is adopted.

No Smoking in Cars with Kids?

The House Health and Human Services Policy and Oversight Committee on Wednesday heard H.F. 379 (Slawik, DFL-Maplewood).  The bill would allow law enforcement officers to issue citations to drivers of cars in which smoking was occurring and a child under 18 was present.  Tickets could be issued only if the driver was stopped for another offense.  After hearing testimony from public health officials, the bill was laid on the table.  Rep. Slawik said that she remains committed to passing the bill, but that the issue is not yet ready to move forward.

Alcohol Prices to Go Up?

The House Health Care and Human Services Finance Division on Tuesday heard two bills that would increase taxes on alcohol to fund CD treatment and law enforcement costs of treating substance abuse.  H.F. 1896 and H.F. 2125 (Clark, DFL-Minneapolis), would increase excise and gross receipts taxes on alcohol, proposals opposed by alcohol retailers and manufacturers.  The bills were laid over for possible inclusion in the omnibus HHS finance bill.  Last year an alcohol tax increase was in the tax bill vetoed by the Governor.

February 19, 2010

Sara Noznesky, MN-AAP Lobbyist

Mark Your Calendar! Peds Day at the Capitol is March 3rd

There are no children in the legislature and no pediatricians elected at the state capitol. Legislators need to hear from you on issues important to you and your patients.

Date: Wednesday, March 3rd
Time: 12:30- 4:00 p.m.
Location:  Minnesota State Capitol

Agenda
12:30   Registration, Capitol Room 118
1:00     MN-AAP issue overview
1:15     Advocacy 101: How to be an advocate for your patients and your practice
1:45     Discussion with key legislators
2:15     Meet with your legislator and attend a Legislative hearing
4:00     Debrief and follow up, Axel’s on Grand Ave. in Saint Paul.

For more information contact either Sara Noznesky at snoznesky*AT*mnmed.org or Melissa DeBilzan at debilzan*AT*mnaap.org.

RSVP to Melissa DeBilzan at debilzan*AT*mnaap.org so that we can set up an appointment for you. Please include your home address in your email so that we can set up a meeting the correct elected representatives.

Pawlenty Releases Budget Changes: Cuts All Around, One Small Positive for VFC Admin Fees

Gov. Tim Pawlenty presented his supplemental budget Monday that outlines how he would erase a $1.2 billion state budget deficit.  Keeping with his ongoing pledge to not raise taxes, his budget recommendations rely on cuts to his familiar targets of health care and local government aid. He also relies on $387 million in federal money that has not yet been approved by Congress.

The budget proposal cuts $347 million from health and human services program. About one-third of those savings would come from reducing MinnesotaCare eligibility for single adults from 250 percent of poverty ($27,084 a year) to 75 percent of poverty ($8,124 a year).  Hospitals and long-term care facilities receive significant cuts. The 1.5 percent rate cut for non-primary care physician services established through unallotment is extended two additional years under the proposal.

For details on the Governor’s budget recommendations click on the following link to the Department of Budget and Management: http://www.mmb.state.mn.us/

The proposed change would result in about 21,500 low-income adults losing their health care. MinnesotaCare is a premium-based program for working Minnesotans that provides subsidies on a sliding scale.  If passed, the only adults without children who would qualify for MinnesotaCare would be those who in past years qualified for the General Assistance Medical Care program.

The proposal also undercuts Minnesota’s efforts to achieve universal coverage and health care reform. The budget proposal includes cutting $10 million from the State Health Improvement Program – a statewide effort to reduce tobacco use and obesity by making communities healthier that was passed as part of Minnesota’s 2008 Health Care Reform Act.

The only silver lining in the budget proposal is the recognition for the need to address issues surrounding the administration fee for vaccines provided under the federal Vaccines for Children program. The proposal increases the amount of reimbursement for administration of non-MNVFC vaccine supplied by the federal government but not in conjunction with an office visit from $1.50 to $8.50. The increase is paid for by suspension of the fee paid to retailers such as grocers for each food support EBT transaction (electronic card payment).

 GAMC Passes the Legislature—Already Vetoed by Governor

What looked like a bipartisan effort to save the GAMC program was abruptly halted by Governor Pawlenty with his veto of a bill to continue coverage Thursday night.

Efforts to maintain coverage for recipients of General Assistance Medical Care (GAMC) coverage continues to move quickly through the Legislature.  Governor Pawlenty has proposed transferring these individuals into the MinnesotaCare program beginning April 1, 2010.  The DFL legislative leaders are proposing maintaining a scaled back GAMC program with a 50 percent cut to physician payments.

The Senate passed an amended proposal Thursday, February 11 to continue the GAMC program. The Senate dropped a funding source that would have assessed a hospital and HMO surcharge designed to draw down more federal Medicaid money, but kept steep reimbursement cuts.  The bill passed on a party-line vote of 45 to 20, with DFL lawmakers supporting it.

Before passing the bill, the Senate dropped the surcharge on hospitals and HMOs in response to indications that Gov. Tim Pawlenty would veto a GAMC fix that included the surcharge.  To pay for the bill, the bill’s author Sen. Linda Berglin, DFL-Minneapolis, proposed using $110 million that was scheduled to be transferred from the General Fund to the Health Care Access Fund in 2011. The $110 million transfer had been scheduled to cover the additional costs expected to occur as a result of the governor’s plan to transfer GAMC enrollees to MinnesotaCare.

The House version of the bill, authored by Rep. Erin Murphy, DFL-St. Paul, was passed on Thursday February 18 with a bipartisan vote of 125-9.  Many looked at this vote as a sign that the Republican Governor would sign the bill.  Surprisingly, Thursday night he announced that he had vetoed the bill because it “does not represent meaningful reform and does not address fundamental cost issues.”  If you’re interested, read the Governor’s veto message.

Legislative leaders said they will attempt to override the Governor’s veto as early as Monday February 22.  In order to be successful they will have to convince at least three House Republicans to vote for the override in order to get the two-thirds voted needed.

Amended Dental Caries Bill Moves Forward

Legislation encouraging physicians to provide basic dental screenings for children as part of their child and teen check up is moving forward.  HF 984 (Norton-DFL, Rochester) was amended last year in response to MN-AAP concerns, from language that mandated that these services be provided by physicians to language that says the Commissioner of Human Services shall encourage physicians to provide these services.  The services would include a general visual exam of the child’s mouth without using probes or other dental equipment, a risk assessment using the factors established by the American Academies of Pediatrics and Pediatric Dentistry, and application of fluoride varnish beginning at age 1 to those children assessed by the provider as being high risk.

The bill passed the House Finance Committee on February 16 and is awaiting final action on the House Floor.

The Senate companion bill SF 633 (Berglin-DFL, Minneapolis) is in the Senate Finance Committee.  It still has the old language mandating the service, but the expectation is that Senator Berglin will adopt the House language.

Complete Streets

On February 16th the House Transportation Policy and Finance Committee held a hearing on Complete Streets policy. The bill, SF2461 (Lourey-DFL, Kerrick) and HF 2801 (Obermueller-DFL, Eagan), implements a “complete streets” policy for state-funded roads. “Complete streets” is a method for planning, scoping, design, implementation, operation, and maintenance of roads in order to reasonably address the safety and accessibility needs of users of all ages and abilities. It is also expected to support safe walking and biking, thereby one of many important policy changes to increase the overall activity level of children and adults alike.

The bill was amended and laid over for further discussion.

Mental Health Professionals Want Authority to Make ADHD Diagnosis

A number of other bills have been introduced that the MN-AAP will be reviewing. HF2995/SF2708 sponsored by Rep. Tillberry (DFL-Fridley) and Sen. Lynch (DFL-Rochester) would allow all mental health professionals to diagnose ADD and ADHD for purposes of identifying a child with a disability in a school setting.

Currently a licensed physician, an advanced practice nurse, or a licensed psychologist is qualified under law to make a diagnosis. Proponents of the bill say that allowing mental health professionals to make this diagnosis would stream line the process and make it easier for parents to bring the diagnosis to the school.

Birthing Centers Legislation Returns, No Requirements to Ensure Safe Outcomes for Newborns

SF2702/HF3046 sponsored by Sen. Linda Berglin (DFL, Minneapolis) and Rep. Maria Ruud (DFL-Minnetonka) would require licensure for birthing centers to be established in the state.  Currently there are no standards for birthing centers in the state, yet a recent Pioneer Press article highlighted a new birthing center in Saint Paul.

The bill establishes licensing standards for facilities not connected to, or associated with, a hospital to perform low-risk deliveries following low-risk deliveries. Low-risk pregnancy is defined to be a “normal, uncomplicated prenatal course as determined by documentation of adequate prenatal care and the anticipation of a normal uncomplicated labor and birth, as defined by reasonable and generally accepted criteria adopted by professional groups for maternal, fetal, and neonatal health care, and generally accepted by the health care providers to whom they apply.” Birthing centers would also be precluded from abortions, general or induction anesthesia and surgical procedures except those normally accomplished during an uncomplicated birth, including episiotomy and repair.

There is no consideration for immediate newborn care currently in the legislative proposal.  The MN-AAP will monitor the bill to ensure safe outcomes for newborns.

Compromise Reached on Limitations to Board of Medical Practice Authority

Legislation to limit the Board of Medical Practice’s (BMP) ability to take action against a physician solely on the basis of prescribing, administering, or dispensing long-term antibiotic therapy to a patient who has been clinically diagnosed with chronic Lyme disease was withdrawn for consideration in the House Health Care & Human Services Policy and Oversight Committee on February 17 following a compromise agreement with the BMP.

The bill SF 1631 (Marty-DFL, Roseville) and HF 2597 (Ward-DFL, Brainerd), would have put the BMP limitation in statute, creating a very bad precedent of having the Legislature tell the BMP how to regulate medical practice and how to define the standard of care.  Under the compromise no legislation will move forward and the BMP will voluntarily agree to a moratorium on taking action related to Lyme disease for up to five years while more study is done on the efficacy of long-term antibiotic therapy for Lyme.

Chiropractic Practice Expansion

The Minnesota Chiropractic Association is planning to introduce legislation to rewrite portions of the chiropractic practice act.  The bill would change the definition of chiropractic from “the science of adjusting any abnormal articulations of the human body…” to “the health care discipline which emphasizes the inherent recuperative power of the body to heal itself without the use of prescription drugs or surgery.  Chiropractic focuses on the relationship between structure, primarily the spine, and function, as coordinated by the nervous system, and how that relationship affects the preservation and restoration of health.”  The bill would also authorize chiropractors to use the term “Chiropractic Physician” with patients.

May 11, 2009

Sara Noznesky, MN-AAP Lobbyist

The Legislature has moved into the final days before the constitutionally-required adjournment date Monday, May 18. Unfortunately, the Governor and legislative leaders have not yet reached agreement on budget items. In order to avoid a special session, a global agreement with the Governor would need to be reached by the end of this week to allow sufficient time to process bills and complete their work on time. While this seems unlikely right now, it is still entirely possible. Stay tuned.

Child Passenger Safety Passes House

The child passenger safety (booster seat) bill (SF99) has passed its final hurdle and could become law by the end of the week. Previously passed by the full Senate, the bill passed the full House this evening overwhelmingly 85-42. Next, the Senate will need to either accept the changes made by the House or reconcile difference in conference committee.

The Governor signed the bill on 5-15-09.

Newborn Screening Bill Still Stalled in the Senate

The newborn screening bill is set for a full House vote on the House floor but has stalled in the Senate waiting for one last hearing. The Department of Health needs this bill to pass this session so they can maintain this critical program and step up parent and provider education about the program.

Please contact your legislators and Gov. Tim Pawlenty to urge them to support a bill that will protect Minnesota’s newborn screening program. This life saving program has been under siege once again this session by privacy zealots so legislators need to hear from you about the importance of this program for children’s well-being.

First Omnibus HHS Bill Passes

The big news this week is that the House and Senate completed work on their Health and Human Services Omnibus bill conference report early Sunday morning after a full week of work concluded with a 20-hour sprint to the finish.

This bill passed both bodies this afternoon but the Governor is expected to veto the bill immediately because the reductions are substantially than he proposed. Nevertheless, the contents of the bill are still important as this will become the base for the second bill.

Following is a summary of relevant provisions:

Article 4, Department of Health

Health Information Technology

  • Requires the  uniform standards to be updated on an ongoing basis and an annual report to  the legislature.
  • Requires the  electronic  health record to be a “qualified electronic health  record—makes other changes to conform with federal law.
  • Authorizes the  commissioner to collect certain data.
  • Establishes a loan  account.

E-Prescribing

  • Requires “backward compatible” and NCPDP SCRIPT
  • Requires the use of E-Prescribing by January 1, 2011.

Prior Authorization and Uniform Formulary
Requires the Commissioner of Health in consultation with the Administrative Uniformity Committee at the Department of Health to develop, by July1, 2009 or in six weeks from adoption of this section, a uniform prior authorization and formulary exception form. All group purchasers must accept this form (including part D) or by phone. An electronic system must be in place by January 1, 2011. Effective January 1, 2011, the uniform drug authorization must be accessible by health care providers, and accepted and processed by group purchasers, electronically through a secure Internet site.

Medication Therapy Management
Requires a Pharmacy Benefit Manager that provides prescription drug services must make available medication therapy management services for enrollees taking four or more prescriptions to treat or prevent two or more chronic conditions. Defines medication therapy management duties—including identifying drug interactions, communication essential information to the patient’s primary care providers and education the patient.

Article 5, Health Care

Outreach Grants
Adds outreach, targeting geographic areas with high rates of families with un-enrolled children and racial and ethnic minorities with health disparities.

School District Enrollment and MA Billing

  • Requires public and charter schools to comply with state health care program outreach requirements.
  • Requires districts to have the applications available, maintains current law requirement that schools designate an enrollment specialist, and requires districts to have a link on their web site on how to obtain an application and enrollment assistance.
  • Allows the commissioner to use an interim rate and then a settle up payment.
  • Establishes an open enrollment process for MnCare that is tied to the public education system.
  • Establishes a “fast lane” process that would blend MNCare and Free and Reduced lunch applications.

Urgent Dental Care Services

  • Authorizes pilots to reduce the total costs to the state dental services provided to persons through emergency rooms.
  • Establishes a subcommittee to the health services policy committee to advise the commissioner on criteria for critical access, coverage, delivery models, and services to be added or eliminated. And study of critical access dental providers.
  • Defines the services that will be eligible for dental coverage for non-pregnant adults.

Health Services Policy Committee
Adds study of reimbursement based on patient-centered decision making, high cost specialty services where there is a high variation in utilization across physicians, and best practice policies to minimize C Sections including standards and guidelines for health care providers and health care facilities.

Non-Payment for Certain Hospital Acquired Conditions.
Adopts non-payment language for the federal nonpayment for never events including hospital acquired infections and medical errors, however, adds additional conditions for non-payment for both hospitals and physicians.

Early Hearing Detection
Increases the newborn screening fee to provide funding for early hearing services to families identified through the universal newborn hearing screening.

Payment Reform
Requires the commissioner by January 1, 2011, to establish performance thresholds for providers included in the provider peer grouping system developed by MDH. Effective January 1, 2012, any provider with a combined cost and quality scores below the threshold shall be prohibited from enrolling as a vendor in state health care programs.

Colorectal Screening
Extends MA coverage to participants who have been screened by the demonstration project and who needs treatment. Allows State-only funded MA to be paid for individuals screened by the demonstration project. Adds an expiration date that coincides with a colorectal cancer prevention demo project—December 31, 2010.

Anesthesiology Payment Limits
Limits the reimbursement for anesthesiology services provided to physicians for the medical direction of CRNA’s shall be the same as the rate paid to CRNA under medical direction.

Pharmacy Rate
Reduces the pharmacy rate from AWP minus 14% to AWP minus 15%. Adds PA’s to list of eligible providers.

Prior Authorization of Diagnostic Imaging
Effective January 1, 2010, requires prior authorization for outpatient CT, MRI, MRA, PET, cardiac imaging and ultrasound diagnosis imagining. Exempts prior authorization for ER, inpatient hospitalization, or concurrent or on the same day as an urgent care facility visit. Allows DHS to contract with a private entity and must be based on evidence based medical literature. Exempts, Medicare and PMAP.

Eligibility Increases
Incorporates a number of eligibility increases for children under 275% of FPG, and also allows children and families to buy MnCare without restrictions under 200%.

Asthma Demonstration Project
Establishes a pilot with at maximum of 200 American Indian Children in first class cities to  include HEPA filters, and other furniture, bedding and equipment to reduce toxins.

Claims and Utilization Data
Requires a report by December 15, 2009 to allow for the release of summary data on claims and utilization for Minnesota Government Programs to the U of M and Mayo and other institutions to conduct an analysis of health care outcomes and treatment effectiveness.

Administration of Publicly Funded Healthcare.
Requires DHS to study the alignment of services to families and children and report by September 15, 2010.

COBRA Premium State Subsidy.
Pays 35% of the COBRA until December 31, 21010 for people who elect COBRA and are eligible for state government programs.

Pilot for Intensive Medication Program
Requires the commissioner to establish a pilot project for an intensive medication program for patients with chronic conditions and a high number of medications.

Managed Care Contracts
Health plans objected to proposals to recapture monies in their reserves but legislators were unwilling to let them off the hook from experiencing cuts like other constituencies in the health care arena. This provision creates a new withhold for health plans and also extends the withhold to county based purchasing. Withhold is 3.5% from January 1, 2010 to December 31, 2010. Effective for January 1, 2011,through December 4%, for calendar year 2012 and 2013 withhold 4.5% and for 2014 goes back down to 3%.

Specialty Provider Payment Ratable Reduction (MA, GAMC, MNCARE)
Effective July 1, 2009, physician and professional services will have a 5% ratable reduction for fee for service, and January 1, 2010 for health plans (PMAP). Certain primary care outpatient services provided by primary care physicians are excluded from the cut (procedure codes 99201 to 99215 and codes 99381 to 99412). PT, OT, Chiropractic and other basic care services are reduced by 3% for FFS and for October 2, 2009 for PMAP.

Based on feedback from the MN-AAP, legislators recognize the need to expand the list of CPT codes and have committed to ensuring all general pediatric services (as well as geriatrics, general internal medicine, family medicine, women’s preventative health and family planning) are protected from cuts when a final budget bill is completed.

C-Section –Blended Rate
Effective October 1, 2009, requires a single rate for the following DRG’s 371, 372, and 373, consistent in the increase of vaginal deliveries and reduction in C-Sections, such that the reduction in C Sections is less than or equal to one standard deviation below the average in the frequency of cesarean births for Minnesota health plan program clients at hospitals performing greater than 50 deliveries per year. Also establishes blended rate for professional services. Eliminates prior authorization.

Article 7, Chemical and Mental Health

Autism Spectrum Disorders Task Force
Creates the Autism Spectrum Disorders Task Force composed of 15 members. Two physicians, one named each by the MN-AAP and MAFP, are included as members of the Task Force. The Task Force is significantly scaled-back from the original proposal which included 28 members.

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