April 14, 2008
Health Care Reform Passes Both the Senate
and House Floors
Health care reform legislation took another
step towards final passage last week when the House approved its
version (HF 3391) on April 10 by a vote of 83-50. The Senate had
passed its version (SF 3099) a few weeks earlier by a vote of
39-23. The bills contain a number of significant differences that
will be worked out in a conference committee that most likely will
begin meeting this week.
Both bills are comprehensive in nature by
expanding coverage for low income Minnesotans, funding grants to
promote public health through addressing obesity, tobacco use, and
alcohol use, adopting insurance reform through standardized benefit
design and reducing administrative costs, and reforming our payment
systems to reward prevention and primary care services. The most
controversy has been related to the payment system recommendations
and the financing of the reforms.
The MAFP has been following these bills very
closely. Our Legislative Committee and Board have had many hours of
discussion on the direction these bills are taking. There are still
many unanswered questions about many of the payment reform
provisions, but we have been very supportive of the direction both
bills take to adopt a medical home, or as the bills call it, a
health care home model. In addition, the MAFP has been very
supportive of the emphasis the bills give to the increased need for
family physicians.
If you are interested in reading the language
of both bills they can be found at the State Legislature’s Website.
The full text of the House bill can be found at
https://www.revisor.leg.state.mn.us/bin/bldbill.php?bill=H3391.5.html&session=ls85.
The full text of the Senate bill can be found
at
https://www.revisor.leg.state.mn.us/bin/bldbill.php?bill=S3099.8.html&session=ls85.
Health Care Homes
The MAFP is very pleased that the medical home model, referred in
the bill as the health care home model, has been fully endorsed in
both the Senate and House bills. By January 1, 2009, the
Commissioners of Health and of Human Services will adopt rules to
begin certifying clinicians who want to serve as a health care
home. The rules will define the final criteria to be certified, as
well as the care coordination fees to be paid and the quality and
outcome standards to be met by the health care homes.
Below is the language of the House bill that
establishes the requirements for health care homes.
Sec. 4. [256B.0752] HEALTH CARE HOME
REQUIREMENTS.
Subdivision 1. Requirement. In order to be certified as a health
care home, a clinician shall meet the criteria specified in this
section and section 256B.0751.
Subd. 2. Patient-provider relationship; care teams. Each patient
of a health care home shall have an ongoing relationship with a
provider trained as a personal clinician to provide first contact,
continuous, and comprehensive care for a patient's health care
needs. Appropriate specialists and other health care professionals
who do not practice in a traditional primary care field, physician's
assistants, and advanced practice registered nurses shall be allowed
to serve as personal clinicians, if they provide care according to
this section.
Subd. 3. Care coordination. (a) The personal clinician, in
coordination with other health care providers, is responsible for
providing or monitoring the patient's health care needs or for
arranging, or assisting with arrangements for, appropriate care with
other qualified professionals. Health care must be coordinated
across all provider types, all care locations, and the greater
community. This coordination applies to care for all stages of life,
including preventive care, acute care, chronic care, and end-of-life
care. Care coordination must include ongoing planning to prepare for
patient transitions across different types of care and provider
types. The care team shall also coordinate with those providing for
the social service needs of the individual, if this is necessary to
ensure a successful health outcome. Care coordination must be
provided in a manner appropriate to the patient's race, ethnicity,
and language. A personal clinician and care team may utilize county
health care and social service providers to satisfy these
requirements.
(b) Selection of a health care home does not limit a patient's
ability to seek care from other providers.
Subd. 4. Care delivery. (a) A health care home must provide or
arrange for access to care 24 hours a day, seven days a week.
(b) Health care homes must encourage the patient, and when
authorized and appropriate, the family or a legally recognized
person as defined in chapter 145C, to actively participate in
decision making as a full member of the primary care team. Health
care homes must consider patients and families as partners in
decision making, and must provide access to a patient-directed,
decision-making process, including appropriate decision aids, when
available.
(c) Care delivery must be facilitated by the use of health
information technology and through systematic patient follow-up
using internal clinic patient registries, according to minimum
standards specified by the commissioners. A health care home must
obtain a patient's written consent prior to making the patient's
medical records available through the Internet.
(d) Care must be provided in a culturally and linguistically
appropriate manner.
(e) Within the context of a system of continuous quality
improvement, care delivery, whenever possible, must be based on
evidence-based medicine and use clinical decision-support tools.
(f) A health care home must provide enhanced access to care,
using methods such as open scheduling, expanded hours, and new
communication methods, such as e-mail, phone consultations, and
e-consults.
(g) Providers certified as health care homes must offer their
health care home services to all their patients with complex or
chronic health conditions who are interested in participation.
Subd. 5. Quality of care. Health care homes must meet process,
outcome, and quality standards as developed and specified by the
commissioners. Health care homes must measure and publicly report
all data necessary for the commissioners to monitor compliance with
these standards.
Subd. 6. Comprehensive care plan. Health care homes must
develop, maintain, and ensure the implementation of a comprehensive
care plan for each enrollee who has a complex or chronic condition,
based upon health history, tests, assessments, and other
information. The comprehensive care plan must meet the criteria
specified by the commissioners. The comprehensive care plan must be
culturally appropriate.
7. Care coordinators. Health care homes must utilize care
coordinators to manage the care provided to patients with complex or
chronic conditions. Care coordinators must be trained to provide
services that are appropriate for the race, ethnicity, and language
of the patient. Care coordination includes:
(1) identifying patients with complex or chronic conditions
eligible for care coordination;
(2) assisting primary care providers in care coordination and
education;
(3) helping patients coordinate their care or access needed
services, including preventative care;
(4) communicating the care needs and concerns of the patient to
the health care home;
(5) collecting data on process and outcome measures;
(6) overseeing the development, maintenance, and implementation
of care plans; and
(7) meeting other criteria as specified by the commissioner.
Payment Reform
An area of controversy with the reform bills since they were
first introduced has been related to the payment reforms
recommended. As introduced, both bills envisioned a system that
would hold providers accountable for the “total cost of care”,
through a system that would require providers to submit annual bids
for the total cost of care that would be used to establish their
fee-for-service payments. This language seemed to be a return to
the failed practice of shifting insurance risk to providers that
would require providers to be in large, integrated systems to be
able to accept that risk. This has been referred to as “level 3”
payment reform.
As a result of strong opposition from
physicians and hospitals throughout the state, that language has
been removed from the House bill. Instead, HF 3391 allows providers
to use “package pricing” for designated chronic conditions as a way
to promote innovative payment systems designed to reward prevention
and reduction of hospitalization. The Senate bill, SF3099, also
includes this package pricing idea, but only as an interim step
towards a total cost of care bidding system.
Because of this difference, the Minnesota
Medical Association has publically supported the House bill and not
the Senate bill. In fact, in the letter the MMA provided to the
House author, they clearly said the MMA “strongly opposes a payment
system based on total cost of care that turns physicians into
insurers and managers of risk. The MMA will vigorously oppose any
efforts by the conference committee to move in that direction.”
House and Senate Differences
Here are the major provisions in the House and Senate bills.
House Bill
The House bill includes the following provisions to reach the
goal of 98% insured by 2013:
Health Care Transformation Commission
- 13-member group tasked with developing a design for payment
reform; establishing a uniform definition and methodology for
calculating relative utilization and health care costs; providing
assistance to providers to participate in the restructured health
care system; and overseeing development of standardized quality
measures, benefit set and cost comparisons.
Access Expansion
- Families with children increased from
275% to 300% federal
poverty guidelines, and adults with no children increased from
215% to 300% FPG—July
2009
- Cap on inpatient hospital services under
Minnesota Care increased from $10,000 to $20,000—July
2009
- More accessible renewal, including one month
grace period before disenrollment
- Removal of the four-month requirement that
MinnesotaCare applicants be uninsured prior to eligibility allowing
individuals to maintain seamless coverage—July
2010
- New premium prices for MinnesotaCare enrollees
based on a new affordability scale—maximum out-of-pocket amount of
8% of income.
- Subsidies between 300% and 400% FPG for
purchase of private coverage so cost no more that 8% of income.
Insurance Reform
-
Analysis of premium rating of high deductible
health plans (per recent media attention)
- Quality Measurement: Develop rules for a
standardized, limited set of measures by which to measure provider
performance including mechanisms to adjust for health status, and
racial, ethnic or language factors that affect quality outcomes;
reduce administrative burden on providers
- Requires Department of Health to recommend a
community benefit standard to be required by law of nonprofit health
plans in the state
- Development of a standardized benefit set
Payment Reform
-
Medical Home and Care Coordination. For
qualified health care homes, a per-patient, per-month care
coordination fee will paid for care coordination services, varied by
care complexity.
Public program enrollees will be encouraged to
select a primary care clinic.
Enrollees with complex or chronic health
conditions will be provided with health care homes.
Certification process for becoming a health
care home involves the ability to provide or arrange for access to
care 24 hours a day; an ongoing relationship with the patient;
ability to provide or monitor health care needs (or for arranging,
or assisting with arrangements for, appropriate care with other
qualified professionals; active patient participation in decision
making; patient registries; continuous quality improvement; care
plans; utilization of care coordinators; participation in health
care home collaborative.
Selection of a health care home does not limit
a patient’s ability to seek care from other providers.
- Quality Incentives. The Commission must report
to the legislature for approval of a risk-adjusted system that links
payment to quality.
- Package Pricing. Rather than proceeding to
total cost of care pricing, the Commission must recommend a
mechanism and standard format to allow providers to set prices for
packages of care for coronary heart disease, diabetes, asthma, COPD,
and depression.
- Single Pricing. Providers may not vary the
amount they accept as payment in full for care included in their
package price with the exception of state public health programs,
workers’ compensation, no fault auto insurance and charity care.
State employee health coverage and all political subdivisions must
be able to pay providers based on their package price (if they offer
a package price) by January 2012.
- Price and Quality Disclosure. By January 2010,
providers must annually establish prices for each procedure,
service, or package of services electronically to the Commission who
will make it publically available.
Public Health
$100 million from the HCAF in grants to local
community health boards to reduce smoking and obesity rates from
2009 - 2011.
Financing
-
The House bill is financed entirely from the
Health Care Access Fund. Earlier estimates placed the cost of the
entire package at $43.6 million in FY09 and $220 million for
FY10-11.
- During floor debate some legislators indicated
they feared the bill, which uses the surplus in the Health Care
Access Fund (HCAF) to pay for expansions to MinnesotaCare and
investments in a Statewide Public Health Improvement Program, will
spend the HCAF down to a zero balance, possibly even spending the
fund into a deficit. An updated fiscal not was not available to
review.
Senate Health Care Reform Contains Stark
Differences
The Senate version of the Reform package passed
last week. Significant differences exist in the Senate version in
the following areas:
Access Expansion
-
Most timelines for expansion contingent upon
meeting cost containment goals and availability of funding.
Insurance Reform
- Technology Assessment. Health Technology
Advisory Committee to assess benefit of medical technology and
devices.
- Section 125
plans. Employers with more then 11 full-time employees must offer
Section 125 tax-status health
plans.
Payment Reform
-
Greater Advisory Role for Providers. Includes a
Technical Advisory Committee to the Transformation Commission made
up of appointments directly from organizations (MMA, Council of
Health Plans, Hospital Association, MMGMA, Chamber of Commerce) to
advise Commission on payment reform and other provider and payer
issues.
- Primary Care Rate Increase. Raises Medical
Assistance fee-for-service rates to primary care providers by up to
50% for those serving in designated primary care shortage areas.
- Total Cost of Care. In addition to voluntary
package pricing, providers may also set a package price for the
total cost of care.
- Single Pricing. Applies to all prices, not just
package prices as in House bill.
Public Health
-
Department of Health to establish a body-mass
index monitoring program to assist in targeting obesity efforts.
- Senate bill also focuses public health efforts
on alcohol abuse and illicit drug use.
Financing
- $39.1 million in FY09 from the HCAF
- Establishes a “health improvement assessment”
(tax) on health plans and hospitals for the public health
improvement program (0.15% on net patient revenue in FY09, then up
to 0.3% [to achieve $40 million in revenue] in FY10-13; expiring
July 2013)
- Establishes a “savings recapture assessment”
(tax) on health plans and third-party administrators for
self-insured plans, beginning January 2010
at a rate to be determined based on actual versus projected savings,
up to 33% of savings.
HHS Budget Differences in Conference Committee
The Legislature is still working to address the
$935 million budget deficit before they adjourn in May. Governor
Pawlenty announced his budget proposal to balance the budget in
March. It included using $398 million from the Health Care Access
Fund (HCAF) over the next three years, including an immediate $250
transfer from the HCAF to the General Fund to fill the hole.
The House and Senate both passed differing
proposals to balance the budget and have now begun efforts to
resolve their differences through the conference committee process.
As previously reported, neither the House nor Senate incorporated
the Governor’s proposal to transfer $250 million from the HCAF.
There are, however, a number of items that will affect physicians.
The most concerning are in the Senate bill. They include:
- Permanent 3% cut to fee-for-service payments
for outpatient services under MinnesotaCare, GAMC and Medical
Assistance, excluding mental health, dental and pharmacy services.
Unfortunately, in most cases the fee-for-service fee schedule is the
basis for the managed care rates for the PMAP programs.
- Increase in health plan withholds by 3% without
language to prevent it from being passed on to providers.
- Increase in prior authorization requirements
for at least 20 more services beginning July
2008 for MinnesotaCare, GAMC and Medical Assistance.
- A $5 surcharge on occupational license fees
that will be deposited in the General Fund in 2009 to help balance
the state budget. Then the funds are dedicated to the Office of
Enterprise Technology to develop an electronic licensing system. The
Board of Medical Practice already has such a system in place funded
by a licensing fee increase in 1999.
The 3% payment cut is troubling at a time when
the Legislature is recommending increasing eligibility for our
public programs. If you are interested in seeing the action alert
the MMA issued to urge contact to legislators to oppose the proposed
3% reimbursement go to:
http://capwiz.com/mnmed/issues/alert/?alertid=11245656&PROCESS=Take+Action
Other MAFP Priorities
- Constitutional Amendment on Health Care:
Legislation to propose a Constitutional Amendment guaranteeing the
right of all Minnesotans to affordable health care has not received
any hearings during the 2008 Session. The bills were introduced
last year and passed a number of committees, however, they have not
moved at all in 2009. The likelihood of action this year is very
small.
- Physical Therapist Direct Access: Legislation
to allow patients to have unlimited direct access to physical
therapists without any physician referral has been amended to
require physician involvement if treatment is needed beyond 90
days. This expands current law from a 30 day limit, but maintains
physician involvement if improvements are not seen within 90 days.
This compromise bill has passed both the House and Senate.
- Pharmacist Administration of Adult
Immunizations: Legislation to allow pharmacists to administer
immunizations to adults and flu shots to children over age 10 is
moving through the Legislature. This bill, as introduced would have
expanded complete immunization authority to pharmacists. The
compromise legislation is limited to all recommended immunizations
for adults and flu shots for all over age 10.
- Internet Prescribing Limitations: Legislation
to clamp down on the use of the internet for prescribing drugs for
illicit use is moving through the Legislature. This is designed to
make it harder for individuals to get a prescription from the
internet without the establishment of a patient-physician
relationship. It is also designed to make it harder for Minnesota
pharmacists to fill these questionable prescriptions. Language is
included in the bill to allow physicians who have an existing
relationship with a patient to use the internet and email to
prescribe needed medications for their patients.
