Minnesota Academy of Family Physicians

GAMC Agreement Passes Senate; House to Act on Monday
On Thursday March 18, the Senate passed legislation to maintain the GAMC program based on an agreement between Governor Tim Pawlenty and DFL legislative leaders. The bill will be acted on by the House on Monday and then on its way to the Governor’s office, where he is expected to sign it into law. (HF 802-Murphy/SF 460-Berglin)

Most stakeholders including representatives of low-income citizens, hospitals and the Minnesota Medical Association support the proposal under the rationale that some kind of program was better than no program. Many legislators are calling this bill significant reform because it pays hospitals a lump sum to provide total care to GAMC patients. The 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 it will be 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.

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Beginning June 1, the program would operate through a “coordinated care organization” (CCO). The 17 hospitals representing about 70% of the GAMC caseload and providing geographic access would be eligible to be CCOs.

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The CCOs are required to coordinate and provide all necessary care for a set fee.

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Outpatient/physician services other than those provided by staff physicians of CCOs are not covered unless they contract with a CCO.

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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.

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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 CCOs.

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 Regional Health Center-Detroit Lakes, Mercy Hospital-Carlton, North County-Bemidji, Mahnomen Hospital, and Rice Memorial-Willmar.

Recommendations on Pediatric Doses for Antipsychotic, ADD/ADHD Medications to be Established
The provision related to ADD/ADHD medication, similar to the one that was in the vetoed GAMC bill has been added back into the deal on GAMC. The section requires the Commissioner of Human Services, in consultation with the Drug Utilization 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 doses listed as needed after consulting the Drug Utilization Review Board.

In addition, the Commissioner shall identify situations where a collaborative psychiatric consultation and prior-authorization are required for drug therapy in pediatric patients, including, but not limited to high-dose regimen, off-label use of prescription medication, a patient’s young age, and lack of coordination among multiple prescribing providers. 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. Jeff Schiff from DHS has indicated that Minnesota has a good track record in this area—and the medical community has not been identified as a group that overprescribes medication for children. This provision has been strongly supported by the National Alliance on Mental Illness (NAMI).

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 their 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. University, Mayo, Hennepin, St. Scholastica, state colleges). In essence, the money follows the students and goes to hospitals, clinics, and pharmacies.

MERC funds go to both 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).

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

House Adopts Budget Guidelines as First Step to Balance Budget
The House adopted preliminary targets to start its process of drafting a balanced budget. The deficit that must be addressed is $994 million. With a continued “no new taxes” mood, most of this will be done through cuts in spending. On March 17, the House Ways & Means Committee adopted the House Budget Resolution that lays out overall targets for each spending area. For the area of HHS, the resolution includes cuts of $155 million. This number includes an assumption that Minnesota will receive $408 million through an increase in federal matching money for Medical Assistance and $147 million of cuts already made for GAMC. If the increase in federal money does not come through and the GAMC bill had not passed, the HHS target would be cuts of $710 million.

What is not included in any of these assumptions is any new money that may come from federal health reform if adopted. If that happens, the size of our state deficit will be significantly less. Because the House wants to wait to see what happens at the federal level we do not expect to see the HHS budget bill before spring break.

Preventive Caries Bill Passes
The bill to encourage primary care physicians to perform primary caries preventive services as part of a child and teen check up passed out of the Senate Health & Human Services Finance Division on March 18, identical to the House bill (SF 633-Sheran/ HF 984-Norton). The MAFP supports this bill.

Last year this bill was drafted to be a mandate for all physicians to provide these services. The MAFP, along with the Minnesota Chapter of the American Academy of Pediatrics, worked with the authors to change it to a voluntary program.

The Senate bill now goes to the full Finance Committee. Since it does not cost the state anything, it should pass quickly out of that committee. The House bill is awaiting final action on the House floor.

ADD/ADHA Diagnosis for Special Education
Legislation to expand the list of health care professionals who can assess ADD/ADHD for the purposes of getting an independent medical plan for kids in school (HF 2995 –Tillberry/ SF 2708 – Lynch) bill passed out of the Education Policy Committees in both the House and Senate and there were several amendments considered. This bill is being pursued by the Minnesota Social Workers Association to allow social workers to address and diagnosis ADD and ADHD for schools.

The bill passed out of the House Education Committee limiting the new authority to diagnose ADD/ADHD to social workers and professional counselors. At one point, 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 completes 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.

The Senate Education Committee also acted on this bill and did not make any additional amendments so the bill would only add social workers to the list of professionals. 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, a psychologist attempted to add the psychometric testing language that was offered and failed in the house, but that amendment was again defeated in the Senate.

No Smoking in Cars with Kids?
The House Health and Human Services Policy and Oversight Committee on March 17 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

Booze Prices to Go Up?
The House Health Care and Human Services Finance Division on March 16 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. Those proposals are 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.

Legislature Passes Committee Deadlines
Friday, March 19, was the Legislature’s second committee deadline. All bills must be through all policy committees by Friday or they are no longer “alive.” This deadline does not apply to the finance and tax committees.

The next committee deadline is Monday, March 29. This is for the divisions of House and Senate Finance Committees to act favorably on omnibus appropriations bills.

The Legislature is likely to recess after the March 29th deadline for an Easter/Passover Break. They are on schedule to finish their work by the third week of May.

- Dave Renner, MAFP Legislative Representative
(drenner@mnmed.org, 612-362-3750, 1-800-342-5662)