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MAO Legislative Update – 3/17/2017

MAO Legislative Update
March 17, 2017
Eric Dick, MAO Lobbyist

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Deadlines Make for Busy Week at Capitol
Moving well into the third month of the legislative session, the first and second legislative deadlines have come and gone.  Each legislative session, legislative leaders set benchmarks by which legislation must clear to remain viable.  Recent weeks have seen committees meet often and late into the evening as they try to process bills.

The next and final deadline is March 31.  By that date bills that have financial or tax impact will have to have been heard in committee. The next weeks will see committees spending much of their time assembling budget bills.  There will also be more action shifting to the floors of the House and Senate, as policy bills make their way through the legislative process.

HPV Vaccine Bill Draws House Author
Legislation to allow minors to offer consent to receive the HPV vaccine without parental consent has drawn a House author to complement the Senate companion.  The bill, authored by Sen. Matt Klein (DFL – St. Paul) and Rep. Jennifer Schultz (DFL – Duluth), amends current law’s provision allowing minors to consent to health care related to pregnancy, STIs, and drug/alcohol abuse.   Sen. Klein is a physician who practices hospital medicine at HCMC.

Unfortunately, the bills are unlikely to receive a hearing or move during this legislative session, as they are opposed by many legislators who are skeptical of both immunizations and minor consent laws.

Prior Authorization Bill Subject of Press Conference, Senate Hearing
A key legislative goal of many physician and patient advocacy groups - reform of the medication prior authorization process (PA) – has seen several important steps forward in recent weeks. The MAO is a supporter of the effort.

The Senate bill, authored by Sen. Carla Nelson (R - Rochester), received a warm reception in the Senate Health and Human Services Finance and Policy Committee on March 9.  Testifying in support was David Agerter, MD, President of the Minnesota Medical Association, sharing with the committee the burden of PA on clinics, as well it's negative impact on patient health and outcomes. Also sharing the perspective of patients was Sue Abderholden, the executive director of the National Alliance on Mental Illness (NAMI-MN).  NAMI joins a group of dozens of other disease and patient advocacy groups in supporting the bill.  Every member of the committee who spoke did so in strong support, with one member, Senator Scott Jensen (R - Chaska) comparing the fight between physicians & patients vs. health plans & PBMs to that of David against Goliath.  The bill was held over for possible inclusion in a larger omnibus to be announced later in the legislative session.

The House author, Rep. Rod Hamilton (R - Mountain Lake) has thus far been denied a hearing for his bill. In an effort to gain some momentum and secure a hearing, Rep. Hamilton called a press conference for Tuesday, March 14.  Rep. Hamilton shared the story of his diagnosis with Multiple Sclerosis (MS), and his struggle to get the medications his physician has prescribed.  It was a powerful press conference, and received significant coverage across the state. Both Dr. Agerter and Ms. Abderholden spoke at the press conference, as well.

Under the bill, health plans would be precluded from changing a patient's formulary in the middle of a patient's enrollment year if the patient is currently taking a drug therapy. The bill has been vigorously opposed by the state's health plans, as well as pharmacy benefit managers (PBM) such as ExpressScripts and Prime Therapeutics. The MMA and its partners have sought passage of PA reform for the last three years, though these special interests have blocked passage.

Quality Measures Alignment Bill Receives Hearings
Efforts to align the quality measures required by state and federal entities was heard in the Senate Health and Human Services Finance and Policy Committee on March 14 and laid over for possible inclusion in a larger omnibus package to be unveiled at a later date.

Under the bill, SF 1340, authored by Sen. Scott Jensen (R – Chaska), the quality measures included in the Statewide Quality Reporting and Measurement System (SQRMS) must align with Medicare’s Merit-based Incentive Payment System (MIPS) measures.  The bill further limits the number of measures that clinics would be required to report to six for a single-specialty clinic and ten for a multi-specialty clinic.  The intent of the bill is to reduce the administrative burden associated with reporting to both the state and federal governments, as the measures required by both were slightly different from one another.

The House bill, HF 1517, is authored by Rep. Matt Dean, the chair of the House Health and Human Services Finance Committee, where it was heard and laid over for possible inclusion in their omnibus bill.

Reinsurance Bill Headed to Conference Committee
With similar – though not identical – bills to subsidize health plans with a reinsurance pool for high cost patients having passed both the House and Senate a conference committee will soon be called to negotiate a single bill to act upon.  Legislators have acted to stabilize the individual market by subsidizing the costs of high risk, high cost patients in the individual market.  This is in result of premium costs in Minnesota's individual market increasing by over 50 percent last year.

The bills are similar in concept though they differ slightly in the funding source, as well as the levels of coverage they’ll provide.  The Senate bill, authored by Sen. Gary Dahms (R-Redwood Falls), funds the pool by transferring $360 million out of the Health Care Access Fund (HCAF) over the course of the next two years.  The House proposal uses less money from the HCAF - $80 million – though it also diverts some premium taxes that would have otherwise been directed to the fund.   The bills also differ in the level of subsidy they provide to insurance companies to cover expenses, with the Senate proposal more generous to the plans.

On the Senate floor, the Senate rejected by a tie vote an amendment authored by Sen. Tony Lourey (DFL – Kerrick) that would have allowed individuals, regardless of income, to purchase their health insurance from the MinnesotaCare program if they lived outside the seven county metro area.  In an effort to address concerns about the low reimbursement rate paid to providers, the amendment included language that raised the reimbursement rate for services provided under these plans from the MinnesotaCare level to that of Medicare, which is still significantly below the rates paid by private insurers.

Both the Governor and Legislature have indicated that they hope to have a reinsurance bill signed into law by the end of March, as health plans are already beginning the rate-setting process for 2018.  The Governor and many DFLers have expressed their opposition to funding the pool largely out of the Health Care Access Fund.

Restrictive Non-Compete Contracts Subject of Senate Hearing
A bill to prohibit the use of non-compete clauses in primary care physician employment contracts was considered by the Senate Health and Human Services Finance and Policy Committee on March 9 where it was passed and referred to the Judiciary Committee.  The bill would render void any contract that places restrictions on the right of a family physician to practice within a geographic area for any period of time after the termination of employment or partnership.  As introduced, the bill would have applied to all physicians, though it was amended to only apply to primary care physicians.

The bill is authored by Sen. Scott Jensen (R – Chaska), a family physician.  The House bill is authored by Rep. Jim Nash (R – Waconia).  Neither the Senate nor House bill completed the necessary committee stops prior to the second deadline, so the bill will almost certainly not advance this session.

Opioid Stewardship Bill Receives Senate Hearing
Authored by Sen. Julie Rosen (R – Vernon Center), a bill to add an assessment called a  “stewardship fee” of one cent per morphine milligram equivalent of opiates sold within the state was heard in the Senate Health and Human Services Finance and Policy Committee on March 9.  The fee, to be paid by the drug manufacturer, was expected to raise as much as $20 million per year, though it’s likely the fee faces opposition and may be altered.

Proceeds from the fee would be used to establish the Opiate Product Stewardship Advisory Council, an 18 member panel made up of physicians, other health care professionals, drug treatment experts, law enforcement, legislators, tribal leaders, and members of families impacted by opioid abuse.  The council would oversee investments in prescriber education, public education efforts, county social services for children and families impacted by opioid abuse, promotion and adoption of best practices related to opioid disposal, and other projects.

The House bill is being carried by Rep. Dave Baker (R – Willmar) though it has not yet received a hearing.  Rep. Baker lost his son to overdose and has been a leader on opioid and other drug issues in the Legislature.

“Any Willing Provider” Measure Heard in Senate Committee
At the beginning of the 2017 Legislative session there was a lot of discussion by legislators about growing concerns with health plans developing provider networks that were very limited.  Questions were being raised about whether these networks were adequate to meet the needs of patients, especially in the rural areas of the state.

One bill to attempt to address this is SF 1738, introduced by Sen. Scott Jenson (R-Chaska), a family physician.  This bill would prohibit a health plan from denying a primary care provider the right to contract with the plan as an in-network provider if the provider is certified as health care home by the Commissioner of Human Services.  The bill defines primary care provider as a physician or APRN in the specialties of family medicine, general internal medicine, general pediatrics, or obstetrics and gynecology, who utilize primary care teams to treat patients.

Supporters of the bill argue that patients need continuous relationships with their primary care physicians to insure the best care and narrow health plan networks interfere with that.  Opponents argue that removing the ability of health plans and accountable care organizations to control the size and composition of their networks will make it harder to control health care costs.

SF 1738 passed the Senate Commerce and Consumer Protection Finance and Policy Committee and was heard in the Senate Health and Human Services Finance and Policy Committee where it was laid over for possible inclusion in an omnibus bill to be developed by the committee at a later date.  The House companion bill did not receive a hearing this year.

Tobacco Taxes Considered in Senate Committee
A series of bills supported by the tobacco industry were considered in the Senate Tax Committee in recent days.  One bill, authored by the chair of the committee, Sen. Roger Chamberlain (R – Lino Lakes) would repeal the automatic tax inflationary increase on a package of cigarettes.  The inflator was included in the landmark 2013 tax bill that increased the tax on a pack of cigarettes by $1.60.  A second bill heard in committee would alter the rate of taxation on e-cigarette devices, effectively making the most commonly available e-cigarette devices – a market dominated by Altria and other large tobacco companies – less expensive relative to other devices.  A third bill considered by the committee would repeal the tax on “premium” cigars – those that retail for more than $3.50.  Testifying in opposition were anti-tobacco advocates, including physicians.

The bills were laid over for possible inclusion in an omnibus tax package to be unveiled later in session.

Several bills sought by tobacco control advocates have also been introduced during the 2017 session, though their fate is uncertain.  One proposal, authored by Sen. Jeff Hayden (DFL – Minneapolis) and Rep. Rena Moran (DFL – St. Paul), would prohibit the use of coupons for tobacco sales.  Tobacco manufactures have increasingly used coupons as a means to negate the increase in tobacco taxes.  Bipartisan bills have also been introduced to fund statewide tobacco cessation phone lines.

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Legislative Update – 3/6/2017

MAO Legislative Update
March 3, 2017
Eric Dick, MAO Lobbyist

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Prescription Monitoring Program Use Debated
Legislation from Rep. Dave Baker (R – Willmar) to mandate the use of the state’s Prescription Monitoring Program (PMP) by all prescribers and dispensers was heard by the HHS Reform Committee on Tuesday February 21, along with a number of other bills to address the continuing opioid crisis in Minnesota.  February 21 was Opioid Awareness Day at the Capitol.

The immediate past president of the Minnesota Medical Association, Dave Thorson, MD testified raising practical considerations related to the use of the PMP.  Dr. Thorson stated that the PMP is a helpful tool to assist prescribers to determine whether a patient seeking opioids may be abusing or diverting them, but he also pointed out that the PMP is not always an easy tool to use.  He stressed the ultimate goal is to embed the PMP into the electronic medical record so a physician will see the patient’s opioid history automatically, but to mandate its use prior to all opioid prescriptions is not the right step.

Partially in response to Thorson’s testimony, the bill was amended to provide a number of exceptions to the PMP mandate.  The PMP would not be required to be checked if opioids were being used to treat cancer, for patients in hospice or diagnosed with a terminal disease, or for 30 days or less for acute pain following surgery, an invasive procedure, or a delivery.

Further discussions with Rep. Baker have limited the requirement to check the PMP even more.  Baker is planning on further amending the bill to only require a check for an initial opioid prescription in the emergency room or an urgent care center.  In all other cases the requirement would only apply upon a refill or continuation of an opioid for more than 30 days.

While this bill in moving in the House, it has not received a hearing yet in the Senate and it is unclear whether it will this year.

Quality Measure Alignment Subject of House Hearing
A bill to align the quality measures required by state and federal entities was heard in the HHS Reform Committee on March 1 and passed to the HHS Finance Committee. Under the bill, authored by Rep. Matt Dean (R - Dellwood), would require the quality measures included in the Statewide Quality Reporting and Measurement System (SQRMS) align with Medicare’s Merit-based Incentive Payment System (MIPS) measures.  The bill further limits the number of measures that clinics would be required to report to six for a single-specialty clinic and ten for a multi-specialty clinic.  The intent of the bill is to reduce the administrative burden associated with reporting to both the state and federal governments, as the measures required by both were slightly different from one another.

The Senate companion is authored by Sen. Scott Jensen (R – Chaska), a family physician.  It’s likely to be scheduled in the coming weeks.

Budget Forecast Paints Somewhat Rosier Picture
The annual February forecast released on February 28 by Minnesota Management and Budget (MMB), the state's fiscal agency, showed an improved budget picture. A balance of $743 million is projected for the current biennium, and a robust $1.65 billion balance is projected in the upcoming 2018-2019 biennial budget. The budget picture even looks positive into the FY 2020-2021 biennium, though MMB notes that the forecast is subject to change, particularly given the significant uncertainty emanating from Washington, DC.

The good budget news should make agreement on a final budget package somewhat easier, as there are more dollars available for both spending and tax cuts.  With the Governor having unveiled his budget proposal in late January, legislators will now use the new forecast to begin the work of assembling their own budget package.  The two sides will have to reach agreement by the constitutionally mandated close of session, set for midnight on May 22 or risk having to return for a special session.

Capitol Pace Quickens as Deadlines Loom
With the first deadline of March 10 fast approaching, many House and Senate committees have been meeting late into the evening.  The HHS Reform Committee, for example, heard 21 different bills over the course of more than five hours of hearings on February 28.  The pace will remain very quick for the next few weeks as legislators rush to move bills through the committee process to “make deadline.”  In an effort to winnow down the number of proposals considered viable, legislative leaders set deadlines by which legislation must pass certain committees.  By March 10, bills must pass through the required policy committees in one body, and the companion bill must clear the committees in the other body by March 17.  A third deadline of March 31 sets the benchmark for finance bills to clear.

House and Senate Consider High Risk Pool Proposals
In an effort to stabilize the individual market by subsidizing the costs of high risk, high cost patients in the individual market pool, both the House and Senate have taken up bills to establish a reinsurance mechanism, though the approach on how to fund it differs between the two bodies.  With premium costs in Minnesota's individual market increasing by over 50 percent last year, legislators are seeking ways to provide some stability in the market.

Both bills provide a state subsidized reinsurance pool that would cover up to 80 percent of the costs of those patients whose annual health care costs are between $45,000 and $250,000 each year.  As currently drafted both bills also uses a portion of the Health Care Access Fund to pay for the reinsurance.  The Senate proposal, offered by Sen. Gary Dahms (R - Redwood Falls) uses a direct appropriation from the Health Care Access Fund (HCAF) of $180 million in each of the next two years. Many provider groups, including the MMA and the Minnesota Hospital Association spoke in opposition, noting that drawing funds from the HCAF would weaken the state's ability to provide coverage to low-income Minnesotans in the coming years.  The proposal does not alter the sunset of the provider tax, currently set for December 31, 2019.  The Senate bill will next be considered by the full Senate Finance Committee.

The House proposal, carried by Rep. Greg Davids (R - Preston), transfers the 1 percent premium tax on health plans that currently goes to the HCAF to the new reinsurance pool. It also takes a direct appropriation of $80 million from the HCAF to provide startup funding for the program.  The bill passed the Commerce Committee on February 28 and was referred to the HHS Policy and Finance Committee.

MinnesotaCare "Public Option" Plan Considered in Committee
The Republican-led Senate considered one of Governor Dayton's central health care proposals for 2017 on March 1.  Under the proposal, carried in the Senate by Sen. Tony Lourey (DFL - Kerrick), all Minnesotans would be eligible to purchase an unsubsidized MinnesotaCare health insurance product regardless of their income. Supporters of the plan argued that it is necessary to ensure that all Minnesotans - particularly those in rural Minnesota where there are fewer choices of health plans - have access to a high quality, affordable health product.  Opponents, including the MMA and the Minnesota Hospital Association (MHA), noted that the public option is cheaper largely because the reimbursement under MinnesotaCare is very low relative to commercial payers; some procedures, they noted, reimburse for as low as 26 percent of commercial insurance.  Many argued that the proposal would lead to even more instability in the individual market as the risk pool shrunk as individuals enrolled in the public option.

No vote was taken on the proposal and it will not be included in any final budget omnibus packages.

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Legislative Update – 2/17/2017

MAO Legislative Update
February 17, 2017
Eric Dick, MAO Lobbyist

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Physicians’ Day at the Capitol a Big Success
Over 160 physicians, residents, and medical residents from around the state gathered in a newly restored Capitol for the annual Physicians’ Day at the Capitol.  The turnout for this years’ event exceeded that of any Day at the Capitol event in recent memory.   The MAO was a sponsor the event.

Attendees heard keynote remarks from Senator Michelle Benson (R – Ham Lake), the chair of the Senate’s Health and Human Services Finance & Policy Committee.  Senator Benson updated the group on the status of a number of MMA priorities, while also providing insight into how to be an effective advocate when meeting with an elected official.  Also providing comment was Sen. Matt Klein, MD (DFL – Mendota Heights), a hospitalist at HCMC.  Senator Klein shared with his physician colleagues his impressions of his first weeks as a Senator.  Senator Klein continues to see patients two nights every week at HCMC.

Following an update from staff on the MMA’s legislative agenda for 2017, attendees scattered throughout the Capitol complex to meet with their legislators.  The event concluded in the evening with a reception in the Rathskaller, the Capitol’s historic dining hall.

Physician Title Protection Bill Introduced
In an effort to strengthen the Board of Medical Practice’s ability to protect the use of the word “physician” when it is improperly used by non-physician health professionals legislation was introduced in late January.  The bills, authored by Rep. Tony Albright (R – Prior Lake) and Sen. Carla Nelson (R – Rochester) essentially restate current law that prohibits the use of terms such as "doctor of medicine," "medical doctor," "doctor of osteopathic medicine," "osteopathic physician," "physician," "surgeon," "M.D.," "D.O.," by non-licensed individuals.  By moving it to a new section it makes it clear that a health care provider licensed a different board is not automatically exempt from this prohibition.

The BMP sought the statutory clarification per the guidance of the state’s Attorney General.  The BMP has been working to preclude a chiropractor who has been advertising his services as a “physician.”

Health Care Workforce Legislation Moves Forward
Four separate bills addressing health care workforce were heard and passed the House Health & Human Services Reform Committee on Thursday, February 16.  All of the bills were developed and promoted by the Legislative Health Care Workforce Commission.  This commission was established in 2014 to address health care workforce shortages.  It was set to sunset on January 1, 2017.  HF 1169 (Albright R-Prior Lake) extends the sunset to 2021 to allow the commission to continue its work.  The Commission is directed to develop a report the Legislature on the projected demand for health professionals and evaluate incentives to attract and retrain workers, especially in the areas of oral health, mental health, primary care, and long-term care workers.

A second bill that passed, HF 744 (Albright R-Prior Lake) establishes a new Minnesota Health Care Workforce Council.  Unlike the existing commission, this council would consist of 29 members representing physicians, hospitals, training institutions, and other providers to provide ongoing program monitoring and coordination to analyze workforce trends and needs and recommend public and private sector efforts to meet our needs.  They shall develop a comprehensive plan every five years, with the first plan by September 30, 2019.

In an attempt to encourage more physicians to serve as preceptors for both medical students and residents, HF 1167 (Schultz DFL-Duluth) creates a tax credit for physicians, APRNs, PAs, or mental health professionals who serve as preceptors.  To qualify for a $5,000 tax credit, a preceptor must serve for at least 12 weeks or 480 hours in a year and receive no additional compensation for that service.  This is purposed as a pilot until 2020, to see if the tax credit helps increase interest in serving as a preceptor.

Finally, the committee passed HF 743 (Albright R-Prior Lake), a bill to establish new training grants for PAs, APRNs, and mental health professional training programs.  The grants can be used for establishing or expanding clinical training programs, recruitment and retention of students and faculty, student financial support, or training site improvements.

Policy Deadlines Loom
In an effort to manage the workflow of the Legislature, legislative leaders each session set a series of deadlines by which legislation must pass to remain viable.  The 2017 deadlines were recently announced, and they will set in place a flurry of legislative activity given how closely they loom.

The first deadline is March 10.  By that date, all legislation must have cleared the relevant policy committees in one body to remain viable.  By March 17, the companion to those bills must clear the policy committees in the other legislative body. And finally, by March 31 all finance and tax bills must have completed the committee process and await action on the House or Senate floor.  April and May will be dominated by floor activity and conference committee negotiations. Session must end no later than midnight on May 22.

Opioid Abuse Continue to Draw Significant Attention
Legislators and state officials continue to press for additional tools to fight the epidemic of opioid abuse and deaths, and a number of bills intended to address the issue have been introduced in recent days.

The state’s Attorney General, Lori Swanson, recently rolled out a package of proposals, including some that are potentially problematic in that they allow law enforcement access to sensitive patient records.

Recently introduced bills include:

  • SF 750/HF 1136 (Sen. Chris Eaton, D – Brooklyn Center & Rep. Dave Baker, R – Willmar)

Under these bills, pharmacies could be disciplined for failing to dispense opioid antagonists such as Naloxone if the drug is in stock and there is a valid standing order in place.

  • SF 751/HF1135 (Sen. Chris Eaton, D – Brooklyn Center & Rep. Dave Baker, R – Willmar)

These proposals would require pharmacists to provide to patients specific information about the risks of opioids and how to dispose of unused medications when the drug is dispensed to a patient.

  • SF 752/HF 1134 (Sen. Chris Eaton, D – Brooklyn Center & Rep. Dave Baker, R – Willmar)

This set of bills would require that opioid prescriptions be filled within 30 days of the date the prescription, after which they would be invalid.

  • SF 753/ HF 1137 (Sen. Chris Eaton, D – Brooklyn Center & Rep. Dave Baker, R – Willmar)

Under these bills, prescribers would be required to check the state’s Prescription Monitoring Program (PMP) database before issuing any prescription for a controlled substance.  The bill provides for several exemptions, including when prescribing or dispensing to patients who are experiencing pain caused by a malignant condition, receiving hospice care, or during an emergency or in an ambulance.  Those who dispense controlled substances would be similarly required to check the database.

  • SF 795/ HF 897 (Sen. Chris Eaton, D – Brooklyn Center & Rep. Debra Hilstrom, D – Brooklyn Center)

These proposals would require all outpatient pharmacies licensed in the state to maintain collection boxes for disposal of legend drugs as pharmaceutical waste.  Such depositories currently exist in many law enforcement offices.

The MMA and other physician groups have joined the effort to prevent addiction and encourage safe prescribing.  Physician groups have strongly supported peer-to-peer education regarding opioid use and prescribing, and  urged caution to legislators as they consider proposals that would interfere directly in the practice of medicine.  The MMA has hosted 20 lectures on issues related to opioid use, abuse, and addiction, and more than 1,000 physicians and medical students have accessed the programming.

Tax Credits for Charity Care Bill Heard in House
Rep. Glenn Gruenhagen (R – Glencoe) has introduced legislation to provide a personal tax deduction to physicians and other health care providers who provide charity care.  HF 156 would require a physician, dentist, chiropractor, advance practice nurse or other provider to file report with the Commissioner of Revenue documenting the amount of charity provided and the value of the care would be calculated based on the Medical Assistance reimbursement rate the practitioner would have received for those services.

The bill passed the House Health & Human Services Reform Committee on Tuesday February 7, and was then heard in the House Tax Committee on Tuesday February 14.  The MMA testified in support of the concept of the bill in both committees.  In the Tax Committee the fiscal note for the bill estimated that physicians provided $91.4 million of charity care in 2016.  The total cost of lost revenue to the state for the tax deduction for all providers is $3.8 million in FY 2018 and $4 million in FY 2019.

The action of the House Tax Committee was to lay the bill over for possible inclusion in the omnibus tax bill.  With no Senate companion yet introduced, final passage of the proposal is in doubt.

Interstate Licensure Compact Fix Continues to Move
A simple bill to provide a technical fix to the Interstate Medical Licensure Compact cleared another hurdle and is being fast-tracked by the Legislature.  Authored by Rep. Tony Albright (R – Prior Lake) in the House, the bill cleared the Civil Law Committee and was sent to the House floor for consideration by the full body.  The Senate bill, authored by Sen. Carla Nelson (R – Rochester), readily passed its first committee stop on February 15th and is set for consideration by the Judiciary Committee on February 20.

The original Compact language, strongly supported by the MMA, other physician groups, and many clinic and hospital systems, passed unanimously in 2015.  The Compact is intended to ease the process of licensure for physicians who wish to practice in multiple states. As the Board of Medical Practice (BMP) started preparing to issue licenses under the Compact, they were told by the FBI that Minnesota's law needed a technical correction to allow them to complete the background check process.

Recreational Marijuana Use the Subject of Two Proposals
Legislators in recent days introduced two proposals related to recreational use of marijuana.  Under HF 927, Minnesota would join eight other states and the District of Colombia in allowing the legal purchase and use of marijuana.  The bill, authored by Rep. Jon Applebaum (DFL - Minnetonka), would allow adults over the age of 21 to legally purchase and posses marijuana.  The bill lays out the structure of a legal cannabis program, including licensure of marijuana production facilities, retail sellers, rule-making for government agencies, and other provisions.  Another proposal, authored by Rep. Jason Metsa (DFL – Virginia), would put the question of legal cannabis before voters as a constitutional amendment on the November 2018 election ballot.

The bills are unlikely to receive hearings.

 

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Legislative Update – 2/3/2017

MAO Legislative Update
February 3, 2017
Eric Dick, MAO Lobbyist

Prior Authorization Reform Bill Introduced
Legislation to reform the medication prior authorization was introduced in both the House and Senate on February 2.  The bills are chief authored by Rep. Rod Hamilton (R – Mountain Lake) and Sen. Carla Nelson (R – Rochester).

The bills have a number of key pieces.  Importantly, the bill precludes health plans from forcing a patient from changing to a different drug therapy during the middle of the patient’s enrollment year.  This provision will provide patients protection from health plans requiring patients to switch drug therapies when a drug that has shown effectiveness is working.  In addition, the bill requires that any approved prior authorization request remains valid for the duration of the enrollee’s contract term.  And finally, the bill contains a number of new disclosure requirements, forcing the health plan to make formulary and related benefit information available at least 30 days prior to annual renewal dates.  Health plans are also required to provide disclosure about changes in formulary and benefit information to patients, prescribers, and pharmacists at least 60 days prior to the change’s effective date.

A coalition of more than 40 groups have gathered to support the legislation, including the MAO and a number of other medical specialties and disease advocacy groups, including the National Alliance on Mental Illness (NAMI), the American Heart Association, the National Multiple Sclerosis Society, the Crohn’s & Colitis Foundation of America, and dozens of others.  More information on the coalition is available here.

Coauthors on the Senate bill include Senators Melisa Franzen (DFL - Edina), Julie Rosen (R - Vernon Center), Michelle Fischbach (R - Paynesville), and Michelle Benson (R - Ham Lake).  Representative Hamilton is joined on the House bill by Representatives Matt Dean (R - Dellwood), Nick Zerwas (R - Elk River), Dave Baker (R - Willmar), Tony Albright (R - Prior Lake), Erin Murphy (DFL - St. Paul), Tina Liebling (DFL - Rochester), Glenn Gruenhagen (R - Glencoe), Roz Peterson (R - Lakeville) and Bob Loonan (R - Shakopee).

Premium Relief Bill Signed into Law
Fast-tracked through the Senate and House and to the Governor's desk, a bill intended to provide relief for consumers facing steep increases in their health insurance premiums was signed into law on January 26.   The bill provides a 25% rebate on the cost of premium for those consumers who purchase health insurance in the individual market but are not eligible for federal tax credits.

Also included in the bill is language intended to help protect consumers who may receive "surprise bills" following hospital or surgery center visits that they believed to be entirely in-network.  In many of these cases, the hospital or surgery center is in-network, but some ancillary services such as radiology or anesthesia were provided by non-network providers.  The language of the bill holds patients harmless, and allows negotiation and arbitration between the non-network physician and the health plan. The original surprise billing language included in the House version of the bill would have capped the reimbursement for out-of-network physician services at the in-network payment level.  Such a proposal, the MMA and other physician groups argued, would unfairly empower health plans in their negotiations with physicians, and would incentivize even more narrow networks.

The bill also contains a provision that allows for-profit HMOs to operate in the state.  Senate conferees rejected a House provision that would have removed all state mandated coverage of conditions and treatments. Requirements that all health plan products cover mental health, maternity care, and cancer screenings along with dozens of other conditions and treatments would have been repealed.

Governor’s Budget Proposal Extends Provider Tax
Governor Dayton unveiled his proposed biennial budget late last month, and legislators soon thereafter began the work of more closely studying the $45.8 billion proposal.  The budget includes almost $2 billion in new spending compared with the last biennial budget.  Legislators will soon begin the work of crafting their own budget proposal in response.

Some notable health care items included in the Governor’s budget include:

  • An extension of the state’s provider tax, the 2% tax on most health care services. The tax is currently set for repeal on December 31, 2019.
  • The proposal shifts more than $700 million in spending for Medical Assistance (MA) from the General Fund to the Health Care Access Fund (HCAF). Medical Assistance has historically been funded from the General Fund, though MA is the single biggest expenditure from the HCAF now.
  • A new “public option” that would allow Minnesotans who purchase in the individual insurance market to buy unsubsidized insurance coverage from the state’s MinnesotaCare program. Governor Dayton’s  office predicted that the average monthly premium for the public option MinnesotaCare option would be $70 less than the average plan offered by private payers such as Medica or HealthPartners.  MinnesotaCare reimbursement to physicians, of course, is far less than that of private third party payers.

Technical Fix to the Interstate Medical Licensure Compact Advances
A technical statutory correction to the Interstate Medical Licensure Compact quickly cleared its first committee stop in the House on January 31.  Authored by Rep. Tony Albright (R - Prior Lake), HF 474 now heads to the House Civil Law Committee for its consideration on February 9.

The original Compact language, strongly supported by the Minnesota Medical Association, other physician groups including the MAO, and many clinic and hospital systems, passed unanimously in 2015.  The Compact is intended to ease the process of licensure for physicians who wish to practice in multiple states. As the Board of Medical Practice (BMP) started preparing to issue licenses under the Compact, they were told by the FBI that Minnesota's law needed a technical correction to allow them to complete the background check process.

The Senate bill is authored by Sen. Carla Nelson (R - Rochester) and is expected to be heard soon.

Palliative Care Council Created Under Bill
Legislation to create a state council focused upon raising awareness of palliative care cleared its first hurdle in the Senate when it passed out of the Subcommittee on Aging and Long Term Care on February 1.  Authored by Sen. Karin Housley (R – Stillwater), the bill establishes the Palliative Care Advisory Committee, a 20 member committee that is to include two physicians, of which one is certified by the American Board of Hospice and Palliative Medicine.  Other committee members include nurses, care coordinators, patient advocates, patients and caregivers with experience in chronic diseases, and legislators.  The group is tasked with advising state government on matters related to the establishment, maintenance, operation, and outcomes evaluation of palliative care initiatives in the state, as well as making annual reports to the Legislature.

The Senate bill passed the committee and was referred to the Senate State Government Finance and Policy Committee.  The House bill is authored by Rep. Nick Zerwas (R – Elk River), and has not yet been scheduled for a hearing.

Physicians Day at the Capitol Set for February 15
Make plans to join your physician colleagues for the annual Minnesota Medical Association’s Day at the Capitol set for February 15.  This day of advocacy and fellowship is an important effort in advancing policies that help physicians and patients, and is a great opportunity for you to directly engage with your legislators on the issues facing organized medicine.  Following presentation from key legislative leaders, individual meetings will be scheduled for you and your local colleagues with your Senator and Representative.   With the extensive three year-long renovation of the Capitol largely finished, it’s a great time to visit the Capitol.

The “White Coats Day” at the Capitol is a key piece of the organized medicine’s advocacy strategy, and your participation is important to our efforts.  Please make plans to join us for this fun and enjoyable day.  More information and registration details are available here.

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Legislative Update 1/20/2017

MAO Legislative Update
January 20, 2017
Eric Dick, MAO Lobbyist

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Premium Relief Bill Headed to Conference Committee
Legislators raced to pass bills to provide relief for those consumers who have seen skyrocketing premium increases in the health plans they purchase in the individual market.  The bills passed both the House and Senate, though in different versions.  A conference committee is expected to begin the work of negotiating a single bill as early as next week.  The Governor and his staff are likely to be heavily involved so that the legislature can vote on a final bill that can be quickly signed into law.

While both the House and Senate provide premium relief, they contain a number of different provisions.  The House bill (Rep. Joe Hoppe, R – Chaska) contains language purported to address the phenomenon of “surprise billing,” those instances where a patient receives care in a hospital or surgery center that is in the patient’s network, but some ancillary services – often anesthesia, radiology, or pathology – is provided by a non-network provider.  In these cases, patients are often surprised to receive bills from those providers that are not covered under their health plan.  Under this House provision, non-participating providers would be reimbursed at the level on in-network providers.  Physician groups have opposed these provisions, arguing that they would effectively strengthen the health plan’s negotiating power.  The language would also incentive health plans creating even more narrow networks.

In addition, the House bill was amended to include provisions that would repeal all of Minnesota’s mandated health coverage.   Gone, for instance, would be a requirement that all health plan products cover mental health treatments, cancer treatment, autism services, and dozens of other conditions and treatments.  Opponents argued that patients don’t plan or schedule a cancer diagnosis or mental health episode, and that a patient’s coverage must anticipate many possible medical needs.

The Senate bill, authored by Sen. Michelle Benson ( R – Ham Lake) does not contain the “surprise billing” language, nor does it include the repeal of mandated coverage of specific conditions and treatments.  It does include a section that would establish a reinsurance pool for those individuals and families with very high health care spending.  The provision would create an entity very similar to Minnesota Comprehensive Health Association, the state’s high risk pool that was dismantled when the Affordable Care Act established guarantee issue and precluded the use of preexisting conditions as disqualifying for coverage.

Both bills focus exclusively on the individual market, a relatively small part of Minnesota’s health insurance landscape.  None of the bills proposed would impact employee-provided health care plans.

The Governor has also proposed relief, though via a different mechanism.  While the House and Senate Republicans’ proposal would use Minnesota Management and Budget (MMB) to administer rebates for those paying high premiums, the Governor’s plan would “buy down” a consumer’s premium via direct payments to the health plans.   Dayton’s proposal is also not means tested, meaning all Minnesotans purchasing in the individual market would be eligible, while the Republicans’ plan uses a sliding scale based upon an individual or family’s income.

Cigar Taxes Cut Under Proposal; Other Tobacco Legislation Likely
The House Tax Committee considered a bill to lower the tax paid on “premium” cigars, those cigar which have a wholesale cost of more than $2.  Current law applies a tax of $3.50 on each of these premium cigars, though the bill would reduce that tax to $.50.  Unsurprisingly, the bill is supported by the tobacco industry, as well as cigar retailers.  Opposition to the bill was led by Minnesotans for a Smoke-Free Generation, a tobacco control coalition on which many physician groups participate.

The proposal was laid over for possible inclusion in a larger tax omnibus bill that will be released later in the legislative session.  No Senate companion has yet been introduced.

Other action on tobacco-related items may yet be considered in 2017.  Tobacco control proponents remain on guard for efforts by the Legislature to preempt local tobacco control efforts.  In recent years many Minnesota cities have enacted local ordinances to restrict the sale of candy and fruit flavored tobacco products to adult-only stores; such products are currently widely available at convenience stores and gas stations. It’s also likely that tobacco interests will once again seek to lower the tax rate on the most commonly available e-cigarette devices that failed to pass in 2016.

More than 600 Bills Already Introduced in Young Session
While the 2017 session is only three weeks old, more than X bills have already been introduced in both the House and Senate.  Very few of these bills will receive a committee hearing, and even fewer will become law. By the close of the session in May, it's likely that more than 4,000 bills will have been introduced.

Some notable bills already introduced include:

  • HF 142 (Thissen, DFL – Minneapolis).  Rep. Thissen’s bill would require the state’s finance agency, Minnesota Management & Budget (MMB), to upon request by a legislator compile an estimate of a bill’s potential impact on the state’s disparities, including health disparities. The model for the proposal is the fiscal note process, the means by which MMB estimates the fiscal impact of legislation.  The bill does note yet have a Senate companion.
  • SF 112 & HF 345 (Housely, R – Stillwater & Zerwas, R – Elk Creek).  These bill would establish the Palliative Care Advisory Committee. The 20 member group, on which at least three physicians will serve, is tasked with consulting and advise the commissioner of the Minnesota Department of Health on matters related to the establishment, maintenance, operation, and outcomes evaluation of palliative care initiatives in the state.
  • SF 143 & HF 96 (Freiberg, DFL – Golden Valley & Eaton, DFL – Brooklyn Center). Introduced but not acted upon in recent years, these bills intend to strengthen Minnesota’s very weak school immunization law by requiring that parent & guardians who wish to not vaccinate their school-age children have a conversation with a physician about the risks of not vaccinating.
  • SF 160 (Clausen, DFL – Apple Valley). Under this bill, the Minnesota Health Care Workforce Council would be established. The council would be tasked with providing ongoing policy and program monitoring and coordination, analyzing trends and changes in health care delivery, practice, and financing, and would recommend appropriate public and private sector efforts to address identified workforce needs.  No House companion has yet been introduced.

White Coat Day at the Capitol Set for February 15
Make plans to join your physician colleagues for the annual Minnesota Medical Association’s Day at the Capitol set for February 15.  This day of advocacy and fellowship is an important effort in advancing policies that help physicians and patients, and is a great opportunity for you to directly engage with your legislators on the issues facing organized medicine.  Following presentation from key legislative leaders, individual meetings will be scheduled for you and your local colleagues with your Senator and Representative.   With the extensive three year-long renovation of the Capitol largely finished, it’s a great time to visit the Capitol.

The “White Coats Day” at the Capitol is a key piece of the organized medicine’s advocacy strategy, and your participation is important to our efforts.  Please make plans to join us for this fun and enjoyable day.  More information and registration details are available here.

 

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Apply Today for a BOG Committee – January 1 deadline

Deadlines Approaching – Apply Today for a BOG Committee

Are you interested in becoming more involved with the AAO-HNS? Consider applying for one of three Board of Governors (BOG) committees: Governance and Society Engagement, Legislative Affairs, or Socioeconomic and Grassroots. The BOG is the grassroots Member network of the AAO-HNS and is composed of local, state, regional, and national otolaryngology societies from across the United States and Canada. Click here for more information on the BOG.

Service on a BOG Committee DOES NOT count toward the maximum of two appointments permitted for Academy/Foundation committees.

The 2017 BOG application cycle opened on November 1 and will close on January 1, 2017. All committee applicants must be in good standing with the Academy and have paid their Academy dues for 2017 no later than Sunday, January 15, 2017.

Click here to apply today!

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[imageeffect type="shadowreflection" align="aligncenter" width="542" alt="MAO Sunset Cruise – August 19" link="http://www.maohns.org/mao-sunset-cruise-august-19/" url="http://www.maohns.org/wp-content/uploads/2016/06/MAOsunsetcruiseflyer.jpg" ]

MAO Sunset Cruise – August 19

 

MAOsunsetcruiseflyer

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Legislative Update 5/31/2016

MAO Legislative Update
May 27, 2016
Eric Dick, MAO Lobbyist
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Session Stumbles to a Close
The 2016 legislative session came to a chaotic close minutes after midnight on Sunday, May 22 with several major bills left incomplete.  The House and Senate passed different versions of a nearly $1 billion bonding bill, and time ran out on before the two bills could be reconciled.  One of the key items on many legislators’ wish list for 2016 – a robust package of investments in new transportation spending – also fell short as the House and Senate could not agree upon how to fund the investments and how much to invest in transit.  A supplemental budget bill did pass both bodies, though many legislators and observers decried the fact that the final version of the bill – totally 599 pages – was released only hours before the House and Senate voted upon the bill.

As of this writing, the Governor was reported to still be considering whether to call a special session to call legislators back to St. Paul to consider a bonding or transportation bill.  Only the Governor can call a special session, and legislators are usually only called back to St. Paul once an agreement on the scope of the session is agreed upon.

The clumsy close to the 2016 legislative session sets the stage for the November elections, when all 201 legislative seats will be on the ballot before voters.  Given the relatively narrow majorities in the GOP-led House of Representatives and DFL-controlled Senate, majorities in one or both bodies may be subject to a change of partisan control.

MAO Activity at the Capitol in 2016
The MAO had a relatively quiet year at the Capitol in 2016.  A long-rumored effort by the professional association of audiologists was not introduced for consideration.  A bill to require state health plans to cover a broader swath of audiology services was introduced though it received no hearings in either body.

Also noteworthy is the fact that the state’s provider tax remains on track for repeal at the end of 2019.  While the Senate heard a proposal to rescind the repeal, it did not receive further consideration and was not included in the final package.  Depending on what occurs in the November elections next year – 2017 – may be a bigger challenge to preserve the repeal.

As noted below, there were several setbacks in relation to tobacco policy.  Advocates for the big tobacco companies were successfully in repealing a piece of the state’s tax law that serves to annually impose an inflationary increase in the tax on tobacco products.  That provision has allowed the tax on a pack of cigarettes to rise by 8-10 cents per pack each year since the provision was passed in 2013.  The tax bill also includes language that effectively reduces the tax on the most commonly used e-cigarettes.  This market is dominated by the big tobacco companies – Altria, Lorillard, and others.

Budget Supplemental Awaits Governor’s Action
For much of the short, ten week session legislators debated how to allocate the state’s $900 million surplus, and the House and Senate adopted very different approaches.  House Republicans emphasized tax relief, while DFLers focused upon new spending.  Given that the House earmarked no additional funding in HHS programs and the Senate called for an increase in health-related spending of more than $60 million, a conference committee of House and Senate legislators was required to negotiate a single finance supplemental.  The final package was not released until mere hours before a vote was taken in the legislative bodies and the package approved.

Notable health care-related pieces included in the omnibus funding package include:

  • Support for mental health infrastructure, including the “Excellence in Mental Health Act,” a provision that will allow the state to seek additional federal funding for mental health treatment.  The bill also includes increases in grants to schools to provide school-based mental health support.  Additionally, the bill directs state agencies to seek new federal funding intended to provide treatment to pregnant and post-partum women who have chemical dependency disorders.
  • An additional $1 million was appropriated to the Medical Education and Research Cost (MERC) fund. MERC is used to support residency training program for physicians and other practitioners.
  • Several health-related licensure bills were included in the package, including formal licensure for genetic counselors and orthotics, prosthetics, and pedorthic-fitters. The language expressly states that physicians who provide these services need not seek separate licensure.
  • A new requirement was passed for health plans to provide notification to enrollees when there are changes to their provider networks. Health plans are required to update their website at least monthly to include changes when providers move from in-network to out-of-network.
  • The Legislature directed the Commissioner of Health to seek additional federal funds for statewide planning, coordination, preparations, and response activities related to the Zika virus. These efforts are related to public health readiness, diagnostic testing of patients, surveillance activities, and mosquito surveillance activities.
  • Additional funds were appropriated for certified community behavioral health clinics. These clinics shall provide coordination of care across different settings and   provider types to ensure seamless transitions for patients.

Also noteworthy are the items not included in the funding package, including:

  • Senate-supported effort to reform the manner in which medication prior authorization is governed. Led by the Minnesota Medical Association with the support of more than 45 disease advocacy groups and physician organizations (including the MAO), the “Fix PA Now” bill received robust support in the Senate but was blocked in the House by bill opponents, including the state’s health plans and pharmacy benefit managers (PBMs) like ExpressScripts and Prime Therapeutics.
  • House-led efforts to prohibit or strictly regulate the University of Minnesota’s medical research any fetal tissue. The House version of the budget bill rejected by conferees would have severely limited the ability of the University to continue much of its research that involves fetal tissue.
  • Senate-supported initiatives to increase reimbursement for primary care physician services by five percent were not included in the final package.
  • Republican-sponsored language to repeal MNsure and move Minnesota to the federal insurance exchange were rebuffed, but new provisions included in the final package provide greater oversight to the legislature on how MNsure can utilize state resources.

Tax Bill Reduces Tobacco Taxes
A large, complex tax bill passed by the House and Senate on the last day contains tax breaks for tobacco interests totaling more than $35 million.  The bill repeals the automatic tax “inflator” for cigarettes, a piece of tax law that has automatically raised the tax on a pack of cigarettes annually.  Also included in the tax package is language that effectively reduces the tax on the most commonly used e-cigarette devices. The vast majority of the market share for these devices is controlled by the major tobacco companies, including Lorillard and Altria.

As of this writing the Governor had not yet signed the legislation.  He has been highly critical of the tax breaks for tobacco.

Legislators Tackle Prescription Drug Abuse
Bills to address the abuse of prescription drugs passed both bodies of the legislature in the final days of the session.  One has already been signed by the Governor, and the second is likely to receive his approval soon.

Signed into law on May 19, SF 1440 expands the authority of pharmacies to collect unused pharmaceutical drugs for destruction.  Authored by Sen. Julie Rosen (GOP – Vernon Center) and Rep. Bob Barrett (GOP – Lindstrom), the aim of the bill is to safely dispose of drugs that may otherwise be diverted for illicit use.  Also included in the bill is language to expand the mechanisms by which pharmacists can dispense naloxone, an opioid-antagonist.  Current law allows pharmacists to dispense the drug if they have a standing order established with a physician or other prescriber.  The new language allows pharmacists to enter into such agreements with the medical consultant of local public health boards or with a designee of the Commissioner of the Department of Health.  Pharmacy advocates had originally sought to grant pharmacists the ability to “prescribe” naloxone, an approach that raised concerns by the Minnesota Medical Association, other prescriber groups, and a number of legislators.

A separate bill awaiting a likely signature by the Governor serves to strengthen the state’s existing prescription monitoring program (PMP).  Authored by Sen. Julie Rosen (GOP – Vernon Center) and Rep. Dave Baker (GOP – Willmar), the bill requires all physicians and other prescribers authorized to prescribe controlled substances with a current DEA registration to register and maintain an account within the PMP.  The effort is intended to increase participation in the database.  Currently only 35 percent of physicians have active accounts with the PMP.  Notably, the bill does not require a physician to consult the PMP before prescribing, that there are a number of legislators interested in pursuing that requirement in a future legislative session.

The bill also grants some new latitude for physicians who are treating a patient they suspect might potentially be abusing a controlled substance to consult the PMP.  The provisions that govern how long the prescription data may be used by the Board of Pharmacy for trend analysis and research was the subject of fierce debate.  The final language allows the use of the data for a period of no more than five years, though that authority shrinks to no more than one year in 2020.

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Legislative Update – 5/13/2016

MAO Legislative Update
May 13, 2016
Eric Dick, MAO Lobbyist
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One Week to Go; Still Waiting for Global Agreement
With the May 23 constitutional deadline just over a week away it is still unclear whether the Legislature will reach an agreement on the major bills all sides have said must get addressed.  There is agreement that additional money is needed for roads, bridges and transit, but there is not consensus on how to pay for investments.  And while most legislators agree on the need for a bonding bill to fund capital projects throughout the state, there is significant partisan disagreement on how large the price tag should be.

Legislators have also not reached agreement upon the use of the state's $900 million budget surplus, with the House Republicans arguing for more tax cuts while the Senate DFL majority advocates for additional new spending.

With just over a week remaining, Capitol observers are split on whether a global deal remains in reach or if the Legislature is headed towards a train wreck with no significant action having taken place.

Some seasoned legislative veterans say there is still plenty of time for the Governor, Senate Majority Leader, and Speaker of the House to set differences aside and reach a deal, while others believe the differences are too great.

HHS Budget Issues Await the Global Deal
There are a number of health and human services budget items that are important to organized medicine that remain stalled until a global deal is reached.  Most of these are in either the House or Senate budget bills that are now in ten member conference committee that is working to reconcile the differences in the two bills.  Notable items include:

The language to fix the flawed medication prior authorization process is included in the Senate bill but not in the House bill. It provides more transparency for patients on what drugs are covered, requires immediate, real-time disclosure prescribers on what drugs require PA, limits how often a patient can be required to get PA for the medications that are working for them, and it shortens the timelines for insurers to approve or deny a PA request.

The Senate increase Medical Assistance reimbursements to physicians for primary care and mental health services by 5 percent. The House does not include any increase.

  • The House increases funding for the Medical Education Research Cost (MERC) program by over $3 million. This money is used to fund training programs for physicians and other practitioners.  The Senate does not include any increase.
  • The Senate increases MinnesotaCare eligibility to 275 percent of the federal poverty level, from the current 200 percent. The House does not increase eligibility.

 Bill Allows More Osteopathic Physicians to Serve on BMP
Legislation allow more osteopathic physicians to serve in the state's Board of Medical Practice passed the House on a unanimous 127-0 vote on May 2, and a similar unanimous vote by the Senate six days later and is soon headed to the Governor for his likely signature. The bill was sought by the Board of Medical Practice.

Authored by Rep. Tony Albright (GOP - Prior Lake) and Sen. Melissa Wiklund (DFL - Bloomington), the bill removes the cap in state statute that sets at one the number of DOs who may serve on the BMP. The bill also adds an additional member to the BMP, raising the number of members to eleven. Technical changes are also included in the bill to the licensing requirement for osteopathic physicians, including updated terminology and making physician testing requirements more uniform.

Greater Access to Opioid Antagonist Sought
Language to allow greater access to the opioid antagonist Naloxone was added to a bill that related to pharmacies’ ability to collect unused medication.  Both the amendment and bill were passed and returned to the Senate for its consideration.

Current law allows pharmacists to dispense naloxone if they have in place a standing order or protocol w/ a licensed prescriber (including physicians, APRNs, PAs).  In fact, all Minnesota CVS stores already make naloxone available using this mechanism now.  This bill adds two other mechanisms to allow pharmacists to dispense naloxone by allowing them to enter into standing orders with either 1) a local public health board’s medical consultant OR 2) with an individual designated by the commissioner of MDH.  It’s anticipated that individual will likely be either the commissioner themselves if they are an physician or other prescriber or the state epidemiologist.  The author of the legislation, Rep. Bob Barrett (GOP – Lindstrom), had originally planned to pursue language allowing pharmacists independent prescribing of naloxone.  Advocates, including the MMA, successfully urged him to take advantage of the means already available under current law.

In addition, the bill tasks the Board of Pharmacy and other stakeholders (including physician’s groups) w/ crafting a “model protocol” to give pharmacies a model to use in crafting these agreements.  A model protocol, advocates reported, will help ease the process of establishing these relationships.

The underlying bill expands the authority of pharmacies to collect and dispose of legend drugs.  Under the bill, individuals and family members of those in long term care facilities would be able to turn in unused or expired pharmaceuticals to a pharmacy for proper disposal.  The bill was sought in an effort to reduce the volume of unused pharmaceuticals that are being diverted for abuse.  The Senate version of the bill is authored by Sen. Julie Rosen (GOP – Vernon Center).

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Legislative Update – 4/29/2016

MAO Legislative Update
April 29, 2016
Eric Dick, MAO Lobbyist

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Three Weeks Left, No Global Agreement
With three weeks left until the Constitutional deadline to adjourn both the Republican controlled House and the Democratic controlled Senate have passed their versions of how to use the state’s $900 million budget surplus, but they are drastically different.

Coming into session in March leaders of both bodies identified three major issues that needed to be addressed this year—passing on a transportation funding bill for roads and bridges, passing a bonding bill to fund state building projects, and agreeing on how much of the surplus should be used for new spending and how much for tax cuts. The approach to how to do each of these remains very different. If the Legislature hopes to complete its work on these and other issues before the May 23 adjournment date there will need to be some compromise by both sides.

Currently both sides are very far apart with little time left, but if there is a willingness to compromise, agreements can still be reached. The sticking issue on a transportation bill is whether it can be funded with the existing surplus (the House position) vs. whether an increase in the gas tax is needed for long-term funding (the Senate position). On the bonding bill it is a question of size, with the House recommending approximately $600 million in projects and the Senate recommending $1.4 billion in projects. Not surprisingly, the two sides differ on the use of the surplus, with House Republicans emphasizing tax cuts and transportation spending while Senate DFLers arguing for new investments in needed programs, including new HHS and education spending.

The next step in the process is for House and Senate leadership to meet, along with Gov. Dayton, to agree on global spending levels that all sides can support. If they are able to reach agreement on these numbers there will be a good chance of them passing the budget bills. If not, we may be heading to the proverbial “train wreck.”

Since the even-numbered years are the second year of the state’s biennial budget, there is no need to pass budget bills to keep the state running. That removes some pressure to compromise. However, with 2016 being an election year for all 201 seats in the Legislature, and with the majority in both bodies at stake, there is pressure to show voters that the party in control can get their work done.

House & Senate Craft Very Different Budget Proposals
House and Senate legislators took two very different approaches to crafting their budget supplemental bills, and the differences in the HHS budget are stark. Both bodies considered and passed their HHS budget pieces this week, though the differences will require a conference committee to reconcile the dramatic differences.

The different approaches began with very different budget targets set by House and Senate leaders earlier in the session. While the GOP House gave the HHS committee a budget target of zero new dollars, Senate leaders allocated additional spending of $43 million in 2017 and $140 million for the 2018-2019 biennium. The House does shift some dollars within its jurisdiction to fund some new programming while cutting spending on other health care programs. The state currently has a projected budget surplus of over $900 million, though there are stark differences in how the House, Senate, and Governor propose to distribute the surplus dollars.

Importantly, the Senate’s version of the HHS budget supplemental includes prior authorization (PA) reforms led by the Minnesota Medical Association and supported by the MAO. While there had been some speculation that the Senate DFL might include language to rescind the sunset of the provider tax, that provision was not included in the package. The provider tax remains set for repeal on December 31, 2019. The Senate bill also includes a 5 percent increase in reimbursement for primary care and mental health services provided for MinnesotaCare and Medical Assistance patients, as well as raising eligibility for MinnesotaCare from 200 percent of the federal poverty level to 275 percent.   Other provisions in the bill would allow physicians limited access to the state’s medical cannabis registry to see if patients are participating in the cannabis program, extend the sunset for use of the All Payer Claims Database (APCD) to better study regional differences in health care utilization, and expand specialty asthma care services under MA for children with difficult-to-treat asthma.

The full Senate considered the bill on April 28 and passed largely on a party line vote. Senators considered a number of amendments related to MNsure and other issues. An effort to strip the bill of $500,000 in funding from the Health Care Access Fund for a study of single-payer health care systems was unsuccessful.

Given its neutral budget target, the House bill contains far fewer provisions. Central to the House Republican’s bill is language to move Minnesota from the existing state-based insurance exchange MNsure to the federally facilitated insurance exchange.   Included in the bill is $1 million in each of the next three years funding for greater Minnesota residency programs, a provision that is also included in the Senate bill. The bill also contains language that would allow patients to authorize or decline individual pieces of consent related to how medical records are used by clinics and hospitals. Many in the health care community, including the Minnesota Medical Association and the Minnesota Hospital Association have opposed this provision on the grounds that it would be extraordinarily difficult to administer and may require physicians to treat patients without allowing clinics to bill the patient’s insurer.

The House also acted on the HHS finance pieces on April 28th in an occasionally fiercely partisan debate that stretched until past 1:00 AM. Dozens of amendments were considered, including amendments related to firearm licensing, MNsure, the licensing of facilities that perform abortions, and other hot-button issues. Unlike the Senate bill which was a single bill funding numerous segments of the state budget, the House has assembled three smaller omnibus bills. The HHS bill was packaged with bills financing public safety and state agency operations.

Many Capitol observers think a budget agreement will not come until mid-May, if at all. Because this is not a budget-setting year, legislators don’t need to craft a budget to keep the government functioning. Most believe that a budget deal may have to come as part of a global agreement that would also include some tax cuts, a bonding bill, and a transportation package. Plans put forward by Senate DFLers and Governor Dayton on these issues remain far removed from that of the House Republican majority.

No Sign of Scope Battles for the MAO; Tobacco Issues Yet TBD
While there had been some speculation prior to the start of the legislative session that the professional association of audiologists might seek a scope expansion or change, no bills have been introduced to that effect and, as such, will not be considered during the remaining weeks of the session. One Senate bill introduced this year would mandate that some audiologist services be covered by health plans operating in the state, though the bill did not receive a hearting.

While there has been no negative actions taken regarding tobacco yet in the session, such changes may yet loom as legislative leaders consider changes to the state’s tax law. Lobbyists for large tobacco interests have sought to repeal a small provision in the tax code that automatically adjusts the tax on tobacco products annually. This “automatic inflator” served to increase the tax on a pack of cigarettes by seven cents on January 1, 2016. Many of these same interests are seeking repeals to the minimum tax on higher cost “premium cigars” as well as a reduction in the tax on the most commonly available forms of e-cigarettes.

House Takes Aim at Fetal Tissue Research
Continuing the focus on fetal tissue research that garnered national headlines in the summer and fall of 2015, the Minnesota House of Representatives included provisions that seek to restrict the use of aborted fetal tissue in research at the University in a higher education finance bill. The bill passed the House on April 25.

Under the provisions, the Dean of the Medical School is required to “attempt to identify sources for procurement of fetal tissues that are available due to the natural death of the fetus and are suitable for

use in academic research” and – when identified – the use of such tissue is to be encouraged.   During committee hearings earlier in the session University President Eric Kaler and Brian Herman, PhD, the university’s Vice President for Research, and Brooks Jackson, MD, the Dean of the University of Minnesota's Medical School presented a strong defense of the University’s use of the tissue in research into spinal injuries, Alzheimer’s disease, and many other conditions. Tissue derived from miscarriage, they argued, often have genetic abnormalities that make them unsuitable for research.

In addition, the bill requires that all research using fetal tissue be approved by the University’s institutional review board, which is required to explore if the research can be conducted using non-human tissue. The language in the House bill further requests that the Office of the Legislative Auditor (OLA) conduct an investigation into the University’s use of fetal tissue in research activities, including the number, type, and cost of fetal research being conducted. The OLA is widely respected by both parties at the Capitol.

The same bill also contains language that attempts to address continued fallout from the suicide of a man enrolled in a University clinical psychiatric drug. The state’s Ombudsman for Mental Health and Developmental Disabilities is tasked with monitoring any drug trials being conducted by the University’s Department of Psychiatry. The Ombudsman is granted additional oversight authority by serving as a receiver of complaints from drug trial enrollees and is authorized to make recommendations to the University on means of corrective action.

These provisions have not received hearings in the Senate, nor have they been included in the Senate’s higher education finance package.

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