Communications: Advocacy News

Legislature Misses Its Deadline; Finishes in Special Session

Friday, May 26, 2017   (0 Comments)
Posted by: Dave Renner, CAE, MAFP Legislative Representative
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Legislature Misses Its Deadline; Finishes in Special Session

The Minnesota Legislature came into the 2017 session in early January with Republican majorities in both the House and the Senate, hopeful for a productive year. They also had the good news of a budget surplus of $1.65 billion to make their task easier.

Even with all of that they failed to complete their work before the Constitutional deadline of May 22. When it looked like they would not reach any kind of agreement with Gov. Dayton on the budget, with just minutes before midnight deadline, May 22, legislative leaders and the governor announced a “framework” for a budget deal.

Based on that framework, where the Governor and legislative leaders set overall spending targets for the different pieces of the state budget an limits on the scope of bills to be considered, the Governor called the Legislature back into special session at 12:01 a.m. on Tuesday, May 23.

The hope of all was that they would complete their work by 7 a.m. Wednesday. At the time many predicted that was too short of a window to process these large, complex bills, and they were right. Only two bills were considered by the House before both bodies recessed with no solution in sight. After another all-night session the Legislature passed their last budget bills early Friday morning and completed their work. It is expected, but not certain that Gov. Dayton will sign the bills sent to him.

For MAFP it was a fairly successful session. First of all, MAFP member Scott Jensen, MD, FAAFP, was elected to the Minnesota Senate. Also, eligibility for our public programs were protected from cuts, the legislature began to address the burden caused by ever-growing quality measure reporting, and increased funding was approved for the University of Minnesota Department of Family Medicine. It was not all possible in that we were disappointed that prior authorization problems were not addressed and there was a retreat from some of the important tobacco taxes.

Higher Ed Increases Family Medicine Residencies

The Legislature also passed the budget bill for the high education programs as part of the Special Session. This bill funds the programs at the University of Minnesota and the state colleges. Included in the final bill is a portion of the Universities request for increased spending. While the University did not get all that they requested, the Legislature did fund the request to increase funding for the University of Minnesota Department of Family Medicine’s residency programs. They Legislature approved an increase of $5.25 million in FY 2018, growing to $7.25 million in FY 2019. This funding was needed to ensure that we can continue to train family physicians in the future.

Prior Authorization Reform the Subject of House Hearing

On May 15 the House Health and Human Services Finance Committee considered legislation to reform the medication prior authorization process, though with legislative deadlines having long passed earlier in the session it was an informational hearing only. While the legislation has seen bipartisan support in the Senate, the opponents, particularly pharmacy benefit managers (PBMs) and health plans, have managed to block consideration of the bill in the House of Representatives. Even though the bill will not move this year, there was overwhelming, bipartisan support for the bill at the hearing.

The bill, HF 747, has been a priority for the Minnesota Medical Association, many other physician specialties, and dozens of patient advocacy groups since its first introduction in 2015. Its author, Rep. Rod Hamilton (R – Mountain Lake) has seen the impact of prior authorization hurdles himself, as he has long lived with Multiple Sclerosis. The bill includes important patient protections and transparency requirements, including a prohibition on health plans forcing a patient from changing to a different drug therapy during the middle of the patient’s enrollment year. In addition, the bill requires health plans to make formulary and related benefit information available to consumers at least 30 days prior to annual renewal dates, while also requiring plans 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.

The Senate companion to the House bill, authored by Sen. Carla Nelson (R – Rochester), had cleared the committee process and was included in the Senate’s omnibus HHS funding package. Advocates hope that the House hearing will result in a desire to move the bill forward in that body next year.

Tax Bill Offers Big Tobacco a Break

A compromise tax proposal unveiled in the hours following the start of the special session offers the tobacco industry several key wins. Under the tax proposal, the automatic tax “inflator” that increases the tobacco tax to keep pace with inflation was repealed, costing the state $10.5 million in lost revenue in the next biennium. The inflator was included in the landmark 2014 tobacco tax increase when the tax was increased $1.60 per pack. The tobacco industry has long sought its repeal.

Also included in the tax bill is a provision that caps the tax on “premium” cigars from $3.50 to $.50 – an 85 percent cut. In a bit of positive news, the bill does close the “man can” loophole. This provision closes a loophole that allowed large containers of moist or chewable tobacco to be taxed at the same rate as small containers.

HHS Budget Bill Uses HCAF to Balance Budget

Like every omnibus budget bill, the health and human services budget bill contains a mixed bag of good and bad items. The good news is that they reached an agreement that does not include any provider reimbursement cuts or any cuts to eligibility for public program recipients. The bad news is, once again, the legislature tapped into the dedicated Health Care Access Fund (HCAF) to cut more from the General Fund to help balance the budget.

At a time when the state had a $1.65 billion surplus the legislature still had to use gimmicks like syphoning money from the HCAF so they could use more General Fund money in other areas of the budget and give larger tax cuts. They also failed to use any of those surplus funds to increase reimbursements in the Medical Assistance and MinnesotaCare programs, even though those reimbursements are so low that providers lose money to care for these patients.

Failure to reach an agreement with Gov. Dayton on the size of spending in the health and human services programs is one reason why the Legislature failed to complete their work and why they were forced to be called into a Special Session.

The agreement that was reached this week reduces General Fund spending for health and human services programs by more than $463 million for the next two years, but the net spending cut is $63 million because a big part of those cuts are offset by increased spending from the HCAF of $391 million.

Once again the HCAF has become a health slush fund that is being used to fund program that have historically been supported by the state’s General Fund. This is especially troubling because the provider tax is scheduled to go away at the end of 2019 and the Legislature has not begun to discuss how they will replace this lost revenue for important health care programs.

Below is a brief summary of some of the key items that are included in the 672 page HHS budget bill:

  • Quality Measurement Burden. Language to address the growing burden of quality measurement reporting is in the HHS budget bill. This language requires the Health Department to cap the number of mandated statewide measures to six for a single-specialty clinic and ten for a multispecialty clinic. These measures must also align with the measures defined by the new Medicare payment system. The measures shall be selected in consultation with a stakeholder group for implementation no later than December 15, 2018.
  • Public Health Response Fund. The bill allocates $5 million to a new Public Health Response Contingency Account, to be used by the Health Department in case of a pandemic influenza or outbreak of a communicable or infectious disease. This is in response to the recent measles outbreak.
  • Opioid Abuse. The bill contains a number of items to address the continuing concern with opioid abuse. It creates two demonstration projects to treat pain without opioids. One is a grant to the Sr. Kenny Institute for a bundled payment to address chronic pain rehabilitation therapy. The second is to study the use of acupuncture to treat chronic pain to determine if it can help reduce the use of opioids.

The bill also establishes opioid abuse prevention pilot projects throughout the state focused to reduce opioid abuse through the use of care teams and community-wide coordination of abuse-prevention initiatives. These projects are based on work done in Morison County that has reduced the amount of abuse and the number of overdoses.

The bill establishes a four-day dose limit for opioids prescribed following treatment of acute dental pain or acute pain associated with refractive surgery. The provision allows an exception to the limit if in the clinical judgement of the practitioner more than a four-day supply is needed.

In response to the concern that measuring pain management as a part of patient satisfaction has resulted in an increase of opioid use, that practice is now prohibited if the patient satisfaction survey is used as part of provider compensation or quality incentive payments.

  • Advance Care Planning. To promote advance care planning related to end-of-life the bill allocates $250,000 each year for two years to Honoring Choices to provide services to individuals, families, caregivers, and providers statewide. This is an increase in funding that Honoring Choices has received from the state for the last two years.
    The bill also creates a new Palliative Care Advisory Council to advise the Commissioner of Health on the establishment, operations, and outcomes of palliative care initiatives in the state. The 18 member council includes two physicians, nurses, other providers, family members, patients, a social worker, and a spiritual counselor who has worked with people with serious illness.
  • Managed Care Oversight. The bill includes a number of provisions related to the oversight of managed care organizations that participate in the Medical Assistance program. It achieves much of its savings by delaying MA payments to health plans by one month. This delay shifts the cost of that payment into the next biennium and results in a one-time savings to this biennium of $173 million.
    The bill includes compliance with new federal managed care rules related to MA. It requires, among other things that managed care plans provide to MA enrollees up-to-date provider directories, drug formularies, including differing medication tiers, and any physician incentive plans. The Commissioner is required to establish a monitoring system to ensure the managed care plans are complying with these requirements, as well as whether they are meeting network adequacy standards. It also requires that at least 85 percent of the capitation payment the health plan receives is spent on providing medical services.
    The bill also authorizes the Office of the Legislative Auditor to audit each managed care organization that participates in the MA program to determine if they are using the public money in compliance with federal and state law.
  • Integrated Health Partnerships. The bill achieves $9.3 million in savings in FY 2018-2019, growing to $34 million in FY 2020-2021 through the increased use of Integrated Health Partnerships, formally known as Health Care Delivery Systems. Payments to these entities shall be population-based that supports care coordination and risk-adjusted. They are primary care based and intended to promote a continuous relationship with the primary care provider.
  • Biomedicine Innovation Grants. The bill allocates a one-time $2.5 million to the University of Minnesota and Mayo Foundation partnership for grants to entities for biomedical and bioethical research. The focus of the grants are for research that will lead to new discovery, has a prospect for commercialization of the research, with strengthen Minnesota’s economy, and is conducted through ethical research practices. The language prohibits the use of any of the funds for research that uses human fetal tissue.
  • Abortion Reporting. The bill amends the current state abortion reporting law to add reporting related to abortions performed via telemedicine. The report must include the facility code for where the patient is seen and the facility code for where the physician is located.

There are a number of provisions that were discussed earlier in the year that were not included in the final health and human services budget bill. They include:

  • Governor Dayton proposed reinstating the two percent provider tax beyond its scheduled repeal date. That was not included in the final bill.
  • The MMA initiative to reform the process of prior authorization for medications was included in the Senate version of the budget bill, but it is not included in the final bill.
  • Efforts to expand the MinnesotaCare program to allow anyone the option of purchasing coverage regardless of income is not included in the final bill. This was an initiative of Gov. Dayton to increase the number of options for consumers in the individual insurance market.
  • Efforts to move Minnesota to the federal insurance exchange is not in the final bill. This was an initiative of Rep. Matt Dean to respond to the criticisms that MNsure is still not working the way it should.
  • The use of a portion of the Statewide Health Improvement Program (SHIP) money to fund the tobacco Quit-line is not included in the bill. The concern was that it would take away from the focus of SHIP of funding local public health programs.

As this goes to press the Legislature is awaiting final action on this bill. Gov. Dayton and the legislative leaders have signed-off on the package but it still needs to pass without major amendments before Dayton can sign it.

MDH Updates Committee on Measles Outbreak

Officials from the Minnesota Department of Health (MDH) provided an update on the measles outbreak to members of the House Health and Human Services Reform Committee on May 10. As has been reported in the press, the measles outbreak continues to spread – primarily among unvaccinated members of the Somali community. Kris Ehresmann, the Director of the Infectious Disease Epidemiology, Prevention and Control Division at MDH, also shared with committee members that the rate of immunizations within the Somali community has spiked, indicating that the increased efforts to promote vaccination has begun to have a positive impact.

Of note, the chair of the committee, Rep. Joe Schomacker (R – Luverne) indicated during the hearing his inclination to consider a vaccine-related bill authored by Rep. Mike Freiberg (DFL – Golden Valley) during the next legislative session. Under Rep. Freiberg’s bill, HF 96, parents and guardians who wish to exempt their children from the mandated childhood vaccines would be required to submit a statement from a physician that provides immunizations verifying that the physician has reviewed with the parent or guardian information about the risks and benefits of the vaccines.

Other efforts to strengthen Minnesota’s weak immunization law in recent years have been blocked by skeptical legislators and a very well organized anti-vaccine community.

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