Legislative Update

March 27, 2009

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 package, 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% payment cut, elimination of most of the optional benefits, and elimination of the Health Care Access Fund.

The Senate Democrats have released an outline of their recommendations to balance the budget.  It 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 area 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 9 to 15%, protects the Health Care Access Fund, and recommends $1.5 billion in new revenues.

These three competing plans will now be debated and eventually melded into a final bill.

PA Changes Moving Forward, APN Bill Appears Dead
Legislation modifying the regulation of physician assistants (PAs) is continuing to move forward.   SF 230 (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.  The MAFP supports this bill.

SF 230 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 the advanced practice nurse (APN) laws do not seem to be moving forward this year. This bill, coming 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.  Dr. Dave Thorson, MAFP Past-President, served as MAFP’s representative on this task force.

The bill, HF 1668 (Murphy), was drafted by the Minnesota Nurses Association and it did not fully represent the recommendations of the task force.  The bill was heard in the House Licensing Subcommittee on March 17.  The MAFP opposed the bill as drafted because it did not require a written collaboration plan for all APNs, only for those who 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.  MAFP Past-President Dr. Randy Rice, the MMA representative to the task force, testified in opposition to the bill as drafted.  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 at all so the bill will not meet deadline.

Licensed Birthing Centers
In an attempt to find savings in the Medical Assistance program, Sen Berglin has introduced legislation to license birthing centers that are outside a hospital and to require pregnant women with a “low-risk pregnancy” to deliver in a birthing center.  The bill,   SF 780 (Berglin), would  license a birthing center, defined as “a health care facility licensed for the primary purpose of performing low-risk deliveries that is not a hospital or in a hospital and where births are planned to occur away from the mother's usual residence following a normal uncomplicated pregnancy.”  It could be staffed by physicians, nurse midwives, or licensed traditional (or lay) midwives.  The bill would cap the fee paid to any facility for a low-risk birth to $1,650 and require health plans to contract with birthing centers. 

The bill was heard in the Senate Health, Housing, and Family Security Committee on March 19.  It was opposed by the MMA, the Minnesota Hospital Association, and many nurse midwives.  The bill was passed and referred to the Senate Finance Committee.

The House version of the bill was heard in the House Health Care and Human Services Policy and Oversight Committee on March 25.  HF 1795 (Ruud) was amended to remove most of the controversy.  It removes any requirement that anyone has to give birth in a birthing center, it eliminates the cap on the reimbursement for delivery services, and it provides liability protection to both physicians and hospitals that may treat complications from a birth at a birthing center.

The differences between these two bills will now be worked out in conference committee.

OB Health Care Home
HF 1346 (Abeler) directs the Commissioners of Health and Human Services to establish “standards of certification for obstetric health care homes for state health care programs.”  While the bill refers to a health care home, it really is promoting a “basket of care” for OB services designed to promote more natural births and less “medicalization” of child birth.

This bill is a problem if we are going to begin creating health care homes for specific conditions.  It is also problematic for the Legislature to begin weighing in on the baskets of care before the work groups they designated to define these complete their work.  The bill passed out of the House Health Care and Human Services Policy and Oversight Committee on March 25 and was referred to the House Finance Committee.

This bill does not have a Senate companion bill so if the idea is to continue to move forward it will have to be amended onto another bill.

Dental Caries Prevention by Primary Care Providers
Legislation related to the provision of dental caries prevention by primary care providers has been changed from mandatory to permissive in the House.  As introduced, the bill would have required all primary care providers to perform a cursory oral examination complete a risk assessment and apply fluoride varnish for low-income patients over the age of one during well child and episodic care visits. The bill would also have required providers to give families caries prevention materials and a list of dentists who accept patients in public programs.

The House version, HF984 (Norton), was heard in the House Health Care and Human Services Policy and Oversight Committee on March 23rd.  Rep. Maria Ruud (DFL-Minnetonka) successfully offered an amendment that replaced the mandate language with a directive to the Department of Human Services to encourage primary care providers to do the additional treatments.  The bill passed and was referred to the House Finance committee for further consideration.

MAFP President-Elect Pat Fontaine, MD, met with Rep Norton, along with the MN-AAP to convince her that it was inappropriate to put into law what services a physician should perform during a patient visit.  Rep. Norton agreed and assisted in amending the bill to permissive language.

The Senate version, SF933 (Berglin) still includes the service as a mandate.  The MAFP will continue to work with the author to change this to the House language.

Newborn Screening Compromise Moves Forward
Legislation designed to allow Minnesota’s newborn screening law to continue is moving forward in a compromise version that has many supporters of medical research upset.  Last year, Governor Pawlenty vetoed needed legislation because of concerns from privacy advocates over the ongoing use of the gathered blood spots without parent’s consent.  The compromise bill met the first deadline by successfully making it through all necessary House policy committees. HF1341 (Thissen), passed the House Health and Human Services Policy Committee on March 19th and the House Civil Justice Committee March 23.  

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.  The bill would allow the department to store specimens longer than two years if parents provided written consent.  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.

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 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 Senate version, SF1478 (Schied) was heard in the Senate Health, Housing and Family Security Committee on March 16.  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 went too far in limiting the use of the samples for important research.  The Senate has until April 7th to pass the bill out of the necessary Senate policy committees to keep the bill moving.

Shared Decision-Making Tools Required for MA
The legislature is contemplating requiring the use of patient-centered shared decision-making tools prior to reimbursing for certain medical procedures.  SF 696 (Berglin) requires “active participation in a patient-centered decision-making process before a referral is approved or reimbursement is paid” for the following conditions: abnormal uterine bleeding; benign prostate enlargement; chronic back pain; early stage of breast and prostate cancers; gastroesophageal reflux disease; hemorrhoids; spinal stenosis; temporomandibular joint dysfunction; ulcerative colitis; urinary incontinence; uterine fibroids; or varicose veins.

While most family physicians acknowledge the value of patient-centered decision-making tools, this legislation raises many unanswered questions.  What tool will be required?  Is this just a new way for health plans to implement a form of prior authorization?  What happens if a patient refuses to participate with the tool?  Is there a reimbursement for the additional time spent with the patient?   Is this tool used by the referring physician or by the physician who is performing the surgery?

SF 696 passed the Senate Health, Housing, and Family Security Committee on March 12 and was referred to the Finance Committee.  The House bill, HF 1140 (Huntley) has also passed the House Health Care and Human Services Policy and Oversight Committee on March 19.  The House author acknowledged that the bill needs more discussion and committed working with physicians to address the unanswered questions before the bill goes forward.

Health Plan PMAP Disclosure
Coverage of all of MinnesotaCare and most of Medical Assistance and General Assistance Medical Care patients 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, increases provided to providers, and the methodology the health plan uses to determine provider reimbursement.  Legislators are accountable for the money that is allocated 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.

Appeals of Death Determinations Defeated
HF 176 (Emmer) would have allowed a determination of death to be challenged in court if a family member, or anyone else, disagreed with the cause of death on a death certificate.  The bill would have stated “A court may find that the cause or manner of death information on a death record is incomplete, inaccurate, or false and may order the registration of an amendment to the vital record.”

This bill came out of a case in the Hennepin County Medical Examiners office where a family disagreed with the finding of suicide on a death certificate.  The family took the case to court and was told that the court did not have authority to rule on the case.  The bill was strongly opposed by the Minnesota Medical Examiners and Coroners Association who argued that the courts are not the right place to be making a medical diagnosis, which is what a determination of death is.  They also argued that this would result in more court cases as any family member could challenge a determination that they did not agree with.

The bill passed the Health Care and Human Services Policy and Oversight Committee overwhelmingly because they believed there needed to be some oversight of people making these decisions.  The bill was defeated on a 4-4 tie vote in the House Civil Law Committee on March 27.  The bill seems to be dead for this session.

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