MAFP Does Well as 2008 Legislature Adjourns
Sunday, May 18
The MAFP had a very good session this year as the Legislature and
Governor reached agreement on the final budget bills just in time to
complete their work and go home. At 11:48 p.m. on Sunday, May 18,
the Legislature adjourned “sine die” and are scheduled to not return
until January 6, 2009.
Despite facing a state budget deficit of $935
million and early versions of health care reform that many believed
were disadvantageous to providers who were not in fully integrated
health care systems, the MAFP was able to ensure our voice was
heard, pass reform legislation with a strong emphasis on primary
care and the medical home model and avoid most problematic
legislation.
We successfully passed a number of public
health provisions and mitigated scope of practice efforts by
physical therapists and naturopaths. Much of the credit for our
success this year is owed to those physicians who are developing
relationships with legislators and getting involved in the process.
Global Budget Deal Reached
After on-again and off-again negotiating sessions throughout the
night of Saturday, May 17, the Governor and legislative leaders
reached an agreement on how to address the projected budget
shortfall.
The overall agreement includes $355 million in
spending cuts, $109 million in tax revenues from changing a loophole
for foreign operating corporations, accounting shifts raising $30
million, and $500 million from the state’s $653 million in budget
reserve funds. The budget packet also includes a 3.9% property tax
cap for three years (something very important to the Governor) and
$60 million in local government aid and $25 million in direct
property tax refunds (something very important to the DFL
Legislature). The property tax issue was one of the major hold-ups
in reaching a deal. Finally, several bonding projects were part of
the deal including the Central Corridor light rail project,
improvements to the Minnesota Veterans Home and the new Lake
Vermilion State Park.
The health and human services budget received
the largest cut – a $229 million reduction during the next year and
a half. Higher education took a $21 million hit. K-12 education
received a one-time increase of $51 in per pupil funding for a total
of $43 million, and nursing homes received a cost-of-living increase
for direct care workers.
What is notable are those things once proposed
to help balance the budget but not included in the final agreement.
Even though the health and human services programs took the largest
percentage of the cuts, physician services did not get cut. Items
not in the final agreement include a proposed 3 percent cut to
outpatient physician services, new prior authorization requirements
for services and procedures based on Oregon’s priority list, and a
$5 licensing fee increase for all professional licenses.
Here is a summary of the key provisions of the
health and human services budget changes:
- Health Care Access Fund (HCAF)
—The bill
includes a one-time transfer of $50 million from the HCAF to the
General Fund on June 30, 2009.
This transfer will be repaid using the projected savings accrued in
the state health care programs as a result of cost saving measures
in the Health Reform bill. Once the savings are projected to reach
$50 million, that amount will be transferred from the General Fund
back to the HCAF. This “loan” from the HCAF is significantly better
than the earlier recommendations to transfer $250 million from the
HCAF and use an ongoing $48 million each year to offset other
General Fund spending on health care programs.
Interpreter Services Quality Initiative—The
bill establishes a voluntary roster and requires the development of
a plan for a registry and certification process for health care
interpreter services. It does not address the issue of how
interpreter services should be paid, but it does start the process
of ensuring minimum quality standards for interpreter services.
Hospital Reductions—The bill delays the
scheduled hospital inpatient rebasing by 24 months beginning Jan. 1,
2009. This saves the state $9.7 million in FY 09 and
$73.4 million in FY10-11. It reduces inpatient hospital rates,
affecting fee-for-service care for Medical Assistance (MA) and
General Assistance Medical Care (GAMC), by 3.46% in FY
2009. In FY2010, the cut drops to 1.9 percent. In
FY2011, the rate cut will change again to 1.79 percent and will
permanently remain at that level. This saves the state $8.3 million
in FY 09 and $16.7 million in FY 10-11. In addition, the bill
proposes a permanent 3-percent rate reduction for outpatient MA and
GAMC fee-for-service care, starting in fiscal year
2009. The final bill does not include a provision that
would have eliminated disproportionate share payments for hospitals
as was proposed in earlier versions of the bill.
HMOs—The bill increases managed care
withholds used by the Department of Human Services from 5% to 8%.
This saves the state $13.6 million FY08-09 and $43.4 million
FY10-11. It also reduces the administrative costs for health plans
that participate in MA, GAMC, and MinnesotaCare to 7% of their
premiums. This saves the state $2.9 million in FY08-09 and $16
million in FY10-11. It does not include provisions from earlier
versions to assess $50 million from health plan reserves.
Health Care Reform
Late Saturday night an agreement was announced on health care reform
that was acceptable to the Governor and the Legislature. The MAFP
supports the final agreement because of the adoption of the medical
home model, which is referred to as the “health care home” in the
bill. The bill begins to change payment systems to reward
physicians for care coordination for those with chronic and complex
conditions through the promotion of the health care home model. It
rewards the provision of quality care through the development of
pay-for-performance methodology that is valid, transparent, and
standardized. It funds statewide health improvement grants to fight
tobacco use and obesity.
It is estimated that the bill will expand
coverage for 12,000 Minnesotans—7,000 will receive coverage under
public programs and 5,000 through new incentives for private
coverage. It includes a provision to require the Commissioner of
Health to convene a work group to make recommendations on the design
of an essential benefit set that includes coverage for a broad range
of services and technologies that are to be determined to be
clinically and cost effective. The recommendations are due by
January 2010.
Article 1: Public Health
- The bill provides $47 million in FY10-11 for
competitive grants to community health boards to reduce obesity and
the use of tobacco. It requires a local match of 10% to receive a
grant and it requires the Commissioner of Health to report on a
sustainable funding source for the future for these grants other
than the HCAF.
- The grants must be based on scientific and
community input and occur in community, school, worksite and health
care settings.
Article 2: Health Care Homes/ Workforce
Shortage
- The bill defines “personal clinician” as a
physician, advanced practice nurse (APN), physician assistant (PA),
or “other health care provider as determined by the commissioner of
health.”
- The commissioners of Health and Human Services
shall develop and implement standards for certification on health
care homes by July 1, 2009. The
focus initially must be on patients with chronic conditions. The
standards must emphasize primary care.
- A personal clinician or a primary care clinic
may be certified as a health care home. If a clinic is certified,
all of the primary care clinicians in the clinic must meet the
criteria of a health care home.
- If initial savings from the health care home do
not accrue, then the Commissioner of Human Services “may make
recommendations to the legislature on reallocating costs within the
health care system.”
- The health care home model must be evaluated
three and five years after implementation to determine if it is
meeting the expected goals.
- The bill directs the care coordination fees
paid as part of the health care home to vary based on the complexity
of the care provided.
- The Commissioner of Health is directed to study
changes needed in health professional licensing to ensure full
utilization of APNs, PAs, and other professionals in the health care
home and primary delivery system.
Article 3: Increasing Access: Continuity of
Care
- The bill provides seamless coverage between MA
and MinnesotaCare for children. A child whose family income rises
above the MA limits may remain eligible for MA for two additional
months and is deemed automatically eligible for MinnesotaCare until
renewal.
- It raises the income cap for parents who are
eligible for MinnesotaCare from $50,000 to $57,500.
- It increases eligibility for adults without
kids from 215% to 250% FPL.
- It allows enrollees who fail to submit renewal
forms to remain eligible for an additional month.
- It requires the Department of Human Services to
use data from the free and reduced school lunch program for the
purposes of identifying children eligible for medical assistance.
- It increases an incentive program for
organizations who assist those enrolling in public programs from $20
to $25 per enrollee.
- It includes a report on automation and
coordination for state health care programs.
Article 4: Health Insurance Purchasing and
Affordability Reform
- The bill includes standards for interoperable
electronic health records and electronic prescribing.
- It Includes payment reform to provide financial
incentives for providers to reduce health care cost, improve quality
and provide more transparency in price. Reforms include
standardized quality incentives, care coordination incentives, and a
peer grouping system that arrays providers based on cost of care and
quality of care.
- It directs the Commissioner of Health to
establish definitions for baskets of care for at least seven
baskets. It specifically directs the commissioner to consider
developing baskets for coronary artery and heart disease, diabetes,
asthma, and depression. If a provider chooses to bill for these
baskets of care then that provider is required to use a single price
for all private payers for these baskets.
- It requires employers with 11 or more employees
to establish Section 125 Plans unless the employer acts to opt-out
of this requirement. These 125 Plans are designed so employees may
purchase individual or employer-based health coverage with pretax
dollars. It provides grants for companies to establish 125 Plans.
- The bill also includes a new tax credit of up
to 20% of the premium cost to help individuals purchase coverage
through the private market.
- It establishes a work group to make
recommendations on the design of an essential benefit set that
includes coverage for a broad range of services and technologies
that are to be determined to be clinically and cost effective with a
report to the Legislature by January 2010.
- It creates a Health Care Reform Review Council,
consisting of 14 members, of which the MMA names two. This council
is to periodically review the progress of implementation of the
reforms in this bill.
- It requires the Commissioner of Health to make
recommendations on a “community benefit standard” to be required of
nonprofit health plans.
- It requires the Commissioner of Health to
develop a plan for a health care affordability program for families
with incomes of 300% FPG.
Driver Safety
The legislature adopted changes for teenage drivers designed to
address the fact the Minnesota has the highest rate of teen driving
deaths in the country. They passed what is called the “Graduated
Drivers License.” For the first six months after teenagers obtain
their license they are limited from driving between 12 midnight and
5 a.m. unless for work or school functions. They are also limited
from having more than one other, non-family member in the vehicle.
For the second six months they can have no more than three other
non-family members in the vehicle. In the 47 other states that have
similar laws, they have seen a reduction in teen accidents.
Two other provisions that the MAFP supported
did not pass. There were efforts to change our seat belt law to make
it a primary offense to not wear a seat belt. This provision passed
the Senate and nearly passed the House. Unfortunately in the end it
did not pass. The same was true with an update to the child
restraint laws. Legislation passed the Senate but not the House to
require children up to age nine to use booster seats when riding in
a motor vehicle, consistent with the recommendations of the National
Highway Traffic Safety Administration.
The MAFP worked with the American Academy of
Pediatrics, the MMA, AAA, and the State Safety Council on all three
of these provisions.
Newborn Screening
Legislation passed to update the newborn screening laws related to
testing of metabolic and genetic conditions. There was a strong push
by privacy advocates to weaken the law by requiring that parents
give informed consent prior to these tests being administered.
There was a concern that requiring parents to “opt-in” for the test,
versus the current option to “opt-out” would have resulted in many
children failing to be tested.
In the end, the law still allows parents to opt
out of the test, but requires those administering the test to
document that parents were provided information on opting out and
that they had a chance to ask questions about the test.
Physical Therapy Direct Access
Legislation pursued by the physical therapists was limited to ensure
that physician care is included in on-going cases. The original
bill would have removed the 30-day limitation on direct access to a
physical therapist and allowed physical therapists to treat patients
indefinitely without ever including a physician in the care. The
MAFP opposed this legislation and argued strongly that physicians
must be included in the care of patients whose conditions go beyond
the expertise of physical therapists.
Based on the actions of the MAFP and other
physician organizations, physician involvement was retained. The
new law allows treatment for up to 90 days without a physician
referral. If the condition shows not improve, the patient must be
seen by a physician before any further PT can be provided.
Retiring Legislators
Following another contentious session, 12 House members announced
their retirement. Eight are Republicans and four are Democrats.
One of those retiring is running for Congress (Rep Paulsen). Since
the Senate is not up for election this year, there were no Senators
making any retirement announcements. Here are the 12 retiring
members.
Rep. John Berns (R-Wayzata)
Rep. Chris DeLaForest (R-Andover)
Rep. Brad Finstad (R-Comfrey)
Rep. Bud Heidgerken (R-Freeport)
Rep. Scott Kranz (DFL – Blaine)
Rep. Frank Moe (DFL – Bemidji)
Rep. Aaron Peterson (DFL – Appleton)
Rep. Dennis Ozment (R-Long Prairie)
Rep. Erik Paulsen (R-Eden Prairie)
Rep. Connie Ruth (R-Owatonna)
Rep. Kathy Tingelstad (R-Andover)
Rep. Neva Walker (DFL-Minneapolis)
- Dave Renner, MAFP
Legislative Representative
(drenner@mnmed.org,
612-362-3750, 1-800-342-5662)
