Monthly Archives: April 2015

Legislative Update 4/17/2015

MAO Legislative Update
Eric Dick, MAO Lobbyist

House Committee Unveils HHS Finance Omnibus
The House HHS Finance committee unveiled its spending package on April 16. The 354 page bill will be the subject of a number of committee hearings next week as the bill is "marked up" or amended. Authored by Rep. Matt Dean (R - Dellwood) with a total price tag of $11.6 billion, the bill contains all state spending on HHS programming.

One of the central pieces of the spending package is repeal of the MinnesotaCare program, a health insurance program that serves low income Minnesotans from 138-200% of poverty and replacing it with what is being called MinnesotaCare II.  In 2013, the DFL legislative majorities expanded the program to qualify as a Basic Health Plan (BHP), a program recognized under the ACA.  Rep. Dean and many Republicans have argued that the current program is too expensive and unsustainable.

Under Rep. Dean's bill, MinnesotaCare is replaced by MinnesotaCare II.  This proposal would shift enrollees to commercial health insurance products purchased on MNSure, the state's health insurance exchange. Importantly, the shift of enrollees to commercial insurance products would be coupled with state tax credits on a sliding scale to individuals and families to subsidize the purchase of enhanced silver-level health insurance products. It remains unclear at this point how affordable the plans would be for many low-income Minnesotans; some have suggested that a family of four would see a yearly increase of $800 in premium costs alone.  Of note, physician services provided under these plans would reimburse at a commercial level and not that of the anemic reimbursement under MinnesotaCare or Medical Assistance. Rep. Dean has stated that his bill would allow for an accelerated repeal of the provider tax.  Current law repeals the tax on 12/31/2019, and a related bill by Rep. Dean would move that repeal up by one year to 12/31/2018.

Other notable spending and policy components in the bill include:

  • A requirement that medical services provided via telemedicine be reimbursed at the same rate as services provided in person. This piece was a major priority for the Minnesota Hospital Association and many clinic and hospital systems.
  • Many changes to MnSure, the state’s insurance exchange. The bill would require DHS to seek a waiver from the federal government to allow individuals to purchase health insurance products directly from health plans and still be eligible for tax credits currently over available on purchases made on the exchange. Other provisions in the bill serve to cap the salary of MnSure officials, make the MnSure executive director an appointee of the Governor, and begin to move the state away from MnSure towards a federal exchange.
  • A requirement that DHS establish a web-based interactive application to help consumers compare local pharmacy prices for the most commonly prescribed drugs.
  • New tools and requirements for DHS to monitor public health care programs to ensure that only eligible enrollees are receiving services. The nonpartisan Office of the Legislative Auditor (OLA) has published a number of reports in recent years pointing to a sizable number of ineligible enrollees receiving benefits.
  • Additional reporting requirements on the managed care organizations (MCOs) that manage the state’s Prepaid Medical Assistance Programs (PMAP) on behalf of the state. The new requirements include reporting on administrative expenses, funds spent on lobbying, marketing, and salaries for health plan executives.
  • Expands the authority of daycares, recreation centers, colleges and universities, and other places to stock and use epinephrine auto-injectors (“Epi-Pens”). The bill requires regular training in the use of the devices for employees while providing “Good Samaritan” liability protections for their use.
  • A requirement that patients be given certain information if a prenatal diagnostic test indicates the presence of a trisomy condition. The MMA and others opposed this provision as intrusion into the physician-patient relationship.
  • A number of provisions related to mental health, including mandated Medical Assistance coverage of pediatric resident psychiatric treatment, improved data collection around suicides, an increase in reimbursement for those who provide chemical dependency treatments, and a pilot program for the diversion of low level criminal offenders with mental illness from jail to treatment centers.
  • Enhanced authority for pharmacists to administer vaccines.   Current law allows pharmacists to administer only influenza vaccines to patients ten and older. Under this provision of the funding bill, pharmacists would be allowed to administer influenza vaccines to patients as young as six while allowing them to administer other vaccines to patients 13 and older. The language also requires pharmacists to both consult the MIIC prior to administering the vaccine and enter it following administration.

Also noteworthy are the things that are not included in the budget. The budget does not include any increases in reimbursement for primary care services. Many physicians groups sought to extend the ACA’s primary care “bump” that brought Medical Assistance reimbursement up to that of Medicare. That enhanced payment ended in December 2014. The funding proposal also eliminates the entire appropriation for the Statewide Health Improvement Program (SHIP), a program that offers grants to schools, cities, and counties to invest in public health infrastructure. First established in 2009, SHIP has been used to fund smoking cessation programs, expand farmers markets, and reduce obesity rates.

The Senate budget proposal is likely to be announced early next week, and is certain to include significantly more spending on these programs.   After passage by both bodies the differences will be negotiated in a conference committee of members from both bodies.

Compact Bill on the Floors
Following a short, unexpected detour to the House Ways & Means Committee, the Interstate Medical Licensure Compact awaits action on the floor of both the House and Senate. The financing of the bill was the subject of some discussion in the Ways & Means Committee, as the fiscal note prepared for the bill originally showed some costs to the Board of Medical Practice. Following additional discussion, the BMP determined that any additional costs could be absorbed through its current appropriations and license fees.

Little opposition has come forward on the bill thus far. The bill has a wide coalition of supporters, including the Minnesota Hospital Association, Allina Clinics, Mayo Clinic, Gundersen Health System, Essentia Health, and others.

Legislators Consider E-Cigarette Tax Cut Proposals
The tax levied on e-cigarettes would be rolled back under a bill considered in the House this week.  The House bill, HF 2182, is authored by Rep. Greg Davids (R - Preston), and was heard on April 16.  The Senate bill, SF 2025 (Sen. Lyle Koenen, DFL - Clara City), had been scheduled for a hearing but was removed.  Many expect it to be rescheduled soon.

Current law taxes e-cigarettes and the e-cigarette liquid used in the devices at a rate of 95% of the products wholesale value. Under the bill, the tax would be based upon the volume of liquid nicotine.  The proposal is widely seen as benefiting those large tobacco manufacturers who sell the "closed system" e-cigarette devices sold in gas stations and convenience stores.  Conversely, the bill would likely increase the tax rate on devices sold in smaller, independent e-cigarette retailers.  Anti-tobacco groups have been highly critical of the bill, as the law would cap the tax going forward, while current law allows the tax to grow as the price of the product increases.  The Raise it for Health Coalition, of which the MMA is a member, also noted that these same devices are far more likely to be used by children and adolescents due to their wide availability.

Tobacco companies such as RJ Reynolds and Altria dominate the e-cigarette market in the United States, particularly in the "closed system" e-cigarette market.

Prior Auth Bill Receives Finance Hearing
The effort to reform the prior authorization process took another step when the bill was heard in the Senate HHS Finance Committee on Friday, April 17.  As was expected, the bill was held over for possible inclusion in the Senate's HHS finance omnibus, which is expected to be unveiled early next week.  The MAO is a member of the coalition supporting the proposal.

During the last committee stop, the bill was further amended to address concerns raised by the Minnesota Council of Health Plans and the Department of Human Services. The heart of the bill remains, and would represent a significant reduction in administrative burden for prescribers while adding important patient protections. The amendment changes some of the timelines for action by health plans included in the original bill, and narrows them to only apply to prescription drugs.   The amendment further clarified that a change to a generic drug from a brand name pharmaceutical is not considered step therapy for the purposes of the bill.

The House version of the bill did not receive any hearings. Given that the language is only contained in the Senate’s version of the HHS Finance omnibus, the bill will be considered as part of the conference committee hearings on the overall HHS budget.

Senate Higher Ed Budget Funds Residency & Medical Education Programs
The Senate Higher Education & Workforce Development Budget Division announced its budget package earlier this week, and it includes significant investments in medical education, residencies, and research. Included in the budget proposal is $346,000 to support the St. Cloud Hospital’s family practice residencies. Also included is $467,000 for supporting the United Family Medicine Residency’s primary care program each of the next two years. And finally, $645,000 in each of the next two years is set aside for graduate family medical education at Hennepin County Medical Center.

Not unlike Governor Dayton’s proposal announced earlier this year, the Senate bill would provide $25 million in additional funding of the University of Minnesota Medical School’s research programming during the next biennum. The bill also provides for grants for research into spinal cord injuries and traumatic brain injuries. The University of Minnesota and the Mayo Medical Foundation also receives just under $7.5 million to fund a joint partnership in genomics research.

The bill also authorizes the University to refinance the existing bonds for the construction of TCF Bank Stadium with the savings earmarked for the predesign and design of improved health education and clinical research facilities of the University of Minnesota Medical School and the Academic Health Center.

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Legislative Update – 4/7/2015

MAO Legislative Update
April 3, 2015
Eric Dick
MAO Lobbyist

Easter/Passover Break Marks Session's Midpoint
Legislators left St. Paul on Friday, March 27th to begin a week-long break for the Easter and Passover holidays following a scramble of late nights of committee meetings. The annual break represents a mid-point in the session and marks the coming of budget hearings and negotiations. With the passage of the second policy committee deadline on March 27th, much of the work of policy committees has been completed, and the action will shift to the committees with jurisdiction on spending and taxing issues.

With the break, many legislators will be holding ‘town hall’ meetings back in their districts. It’s a terrific opportunity to visit your elected official to share with them what issues are important to you. Legislators want to hear from physicians and physicians-in-training, and these visits can be very impactful. Legislators return to St. Paul on Tuesday, April 7 for the final sprint toward a late-May adjournment.

No Scope of Practice Changes for Audiologists Introduced
With the passage of the policy deadlines in recent weeks, no legislation to expand the scope of practice for audiologists has been considered. In recent years, such bills have often been considered both in St. Paul and at the federal level in Washington, DC. These bills can put patients at risk be expanding the scope of audiologists to include procedures in which they are not adequately trained.

The MAO Advocacy team continues to watch for other legislation that would be detrimental to otolaryngologists and patients. Unlike in years past, there have also been no efforts to extend the state’s sales tax to “cosmetic” surgical procedures.   Proposals such as these often contain inaccurate or ill-defined definitions of what constitutes a “cosmetic” procedure, and compliance with the law would lead to intrusion in a patient’s medical records. And finally, all physician services are subject to the provider tax.   (Note: The provider tax is set for repeal at the end of 2019 and no proposals to rescind the repeal have been introduced.)

Prior Auth Reform Misses Deadline
The MMA-led effort to reform the laws governing prior authorization took a blow recently when the House HHS Reform declined to hear the bill before the Legislature’s second deadline for acting upon bills. While the bill had passed the necessary policy committee in the Senate with little opposition from legislators, opponents – particularly the health plans and pharmacy benefit managers (PBMs) successfully blocked the bill’s consideration in the lower body.

While certainly a setback, the door has not yet closed on moving the bill in its entirety or in smaller pieces. The authors of the legislation, Sen. Melisa Franzen (DFL – Edina) and Rep. Tony Albright (R – Prior Lake), have expressed interest in pursuing other mechanisms to enact some elements of the bill. It’s possible that the bill could be included in a larger omnibus package of HHS finance-related provisions, and it’s possible that pieces could be amended into other bills. This remains a priority issue for the more than 40 organizations that support its passage, a coalition that includes the MAO. The full list of supporters and additional information can be found on the website.

Budget Targets Announced by House, Senate Leaders
The work of setting a state budget for the state began in earnest last week when both the House Republicans and Senate Democrats announced their budget targets. These numbers set overall spending for both the entire state government and individual areas within state government (e.g. K-12 education, HHS, transportation, etc.). While the Senate targets are largely in line with the figures proposed by Governor Dayton in mid-March, the House Republican targets are very different.

Presented in a press conference by GOP House Speaker Kurt Daudt (R – Crown) and Rep. Jim Knoblach (R – St. Cloud), the chair of the budget-writing Ways & Means Committee, the Republicans propose overall state spending of just under $40 billion for the 2016-2017 biennium, with an additional $2 billion in unspecified tax cuts. Included in their spending numbers is $11.6 billion in the HHS budget. Republican leaders argued that the HHS number represents an increase of more than $400 million over 2014-2015 levels, while their DFL opponents noted that the figure is more than $1.1 billion less than the projected HHS spending for 2016-2017 that is included in current law.

Later in the week Senate Democrats then put forward their budget targets on March 27, and their budget more closely matches that put forward by Governor Dayton earlier in the year. Their budget provides for biennial spending of $42.7 billion, including an additional $341 million in HHS funding above current projections. Senate Majority Leader Tom Bakk (DFL – Cook) noted in his budget announcement that increased funding for loan forgiveness for rural physicians remains a high priority.

One of the central questions in the HHS funding debate will be the future of MinnesotaCare. During the last legislative session, the Legislature amended MinnesotaCare to qualify as a “Basic Health Plan” (BHP) as allowed under the ACA. The only BHP in the country, the plan provides robust health coverage to enrollees with very limited out-of-pocket expenses. Critics have suggested that the program as constructed is too expensive and not sustainable. One of those critics, Rep. Matt Dean (R – Dellwood), the chair of the House HHS Finance Committee, has proposed an alternative. Under Rep. Dean’s bill (HF 1665), the current MinnesotaCare program would be repealed and replaced by a new system dubbed “MinnesotaCare II.” Enrollees would be given state subsidies and required to purchase silver-level health plans through MnSure, the state’s health insurance exchange. The advantages of MinnesotaCare II would be that payments to physicians and other providers would be at commercial rates instead of the extremely low MA rate, and it would reduce pressure on the state’s 2% provider tax, scheduled to be repealed in 2019.It’s not yet clear what these health plans would look like in terms of out-of-pocket expenses, copays, or deductibles and whether the projected higher cost-sharing requirements will be too burdensome for low-income Minnesotans to afford. Senate leaders and Governor Dayton’s office have indicated that they are strongly opposed to any proposal that dismantles MinnesotaCare in its current form.

The finance committees in both bodies will begin to craft their budgets upon their return from the Easter/Passover break. Given the expected differences between the two approaches, Senate and House leaders – likely in conjunction with the Governor and his top officials – final action will require conference committees and behind-the-scenes negotiations.

Tax on Premium Cigars Rolled Back Via Bill
The state's enhanced tax on "premium" cigars would be dramatically reduced under a bill heard in the House Tax Committee on March 25. The bill is authored by Rep. Jim Nash (R - Waconia). The House file was held over for possible inclusion in an omnibus tax bill that will be unveiled later in the session. The Senate bill, carried by Sen. Dave Senjem (R - Rochester) is set for a hearing shortly after legislators return from the Easter/Passover break.

Under current law, hand-rolled cigars that have a wholesale cost of more than $2.00 and whose wrapper is entirely made of tobacco are defined as a "premium cigar." These items are taxed at 95% of the wholesale value, though is capped at $3.50. This bill would lower that cap to $.50.

A number of individuals testified in opposition, including Twin Cities physician Lisa Mattson, MD, arguing that making tobacco less expensive serves no public good. The bill is being sought by tobacco retailers and the Cigar Association of America.

Physician Assisted Suicide Bill Receives Informational Hearing
A bill to allow physician-assisted was introduced in both the House and Senate, though the authors quickly acknowledge their intent to not pursue them this year but use the bills to start a broader, statewide conversation about the issues of patient decision-making and autonomy at the end of life.

The Senate took up SF 1880, authored by Chris Eaton (DFL - Brooklyn Center) in an informational hearing on March 23. Senator Eaton was joined by David Grube, MD, an Oregon family physician and the National Medical Director for Compassion & Choices. Also speaking in support was a woman whose parents had extended, difficult deaths who had stated their interest in assisted suicide.   No official action was taken at the hearing, and no hearings are anticipated for the House bill, authored by Rep. Mike Freiberg (DFL - Golden Valley).

Under the bill, terminally ill patients would be allowed to request from their physician medication intended to aid in hastening death. The bill lays out a number of requirements that must be included in the request, including the number and type of witnesses to a patient's request, as well as multiple statements of intent made by the patient over the course of at least 15 days. The bill further specifies the role of attending physicians, including a requirement that they inform the patient of the prognosis, make a determination of competency, provide extensive documentation in the patient's medical record regarding the patient's wishes, and other requirements. The bill requires patients to "self-administer" the lethal medications. The bill is modeled after Oregon's assisted suicide legislation, in place since 1998.




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