Advocacy Rounds

1. Advocacy Rounds 2009 Legislative Wrap Up What happened in St. Paul? What does it mean for you and your patients? Dave Renner, Director Federal and State Legislation Sara Noznesky, Manager State Legislative Affairs

2. Advocacy Rounds • 2009 Legislative Session overview • MMA budgetary priorities • Additional issues impacting physicians and patients • What next?

3. Legislature’s Job One:Balance Budget • Convened January 6 • In odd-numbered years, required to budget for next two years • Constitutionally required to balance budget • Adjourned May 18 • Fiscal Year ends June 30

4. Historic Deficit $6.4 Billion Deficit (17% state budget) - $1.8 Billion Federal Stimulus Money $4.6 Billion Net Deficit • Economy continued downward, making budget gap larger • Details on federal stimulus funds slow to emerge • Controversy: • New taxes? • More cuts? • Combination of both?

5. General Fund Spending

6. Health Care, the Budget Buster • Health care spending projected to grow 26% over 2010/2011 • Growing number of uninsured along with job losses • Safety net takes on new meaning for more Minnesotans

7. Governor Released Budget Proposal in February • Eligibility cuts • Inpatient General Assistance Medical Care • Adults without children on MinnesotaCare • Eliminate HCAF, transfer all revenue to General Fund • Establish uncompensated care pool • Cut physician reimbursement 3% • Eliminate rehabilitative benefits • Committed to no tax increases

8. MMA Budgetary Priorities • Protect safety net eligibility • Prevent reimbursement cuts, achieve increases over long-term • Preserve benefit levels • Oppose provider tax increase • Maintain Health Care Access Fund integrity • Solve deficit with balanced approach: cuts and new revenue

9. Legislature Rebuffs Governor • House and Senate respond: • Reject misuse of HCAF • Reject eligibility cuts • Reject benefit cuts • Accept rate cuts • Micromanagement of delivery of care • Tax increases: income, alcohol, tobacco

10. Ended On Time but Not Within Budget • No special session, no government shutdown • Most areas of government cut (except K-12) • Still no balanced budget • $2.7 billion gap remains • Governor now has authority to “unallot”

11. What is Unallotment? • Power to cancel or reduce appropriations to balance budget • Must first exhaust budget reserves ($250M) • Cannot raise revenue or transfer between funds • Applies to any fund with a projected deficit (incl. HCAF) • Used only 4 times, usually call special session • Cannot act until July 1, will announce reductions sooner • Hope Governor will consult stakeholders • Early indications suggest K-12 funding shift and cuts to local governments, welfare services, and health care and human services

12. “Final” Result • MMA helped shape debate • Some eligibility cuts • General Assistance Medical Care eliminated July 2010 (FY2011) • 35,000 childless adults making <$7,800/yr • Many with chronic disease and mental illness • Hospitals feel majority of impact • Possible federal solution?

13. “Final” Result, cont. • Payment cuts for specialty physicians, hospitals, pharmacists, health plans and other providers • 5% reduction for specialty physicians effective July 1 • PMAP payments also reduced • Excludes outpatient visits, preventive medicine, or family planning services in primary care practices (general practice, general internal medicine, general pediatrics, general geriatrics, and family practice) • Also does not apply to federally qualified health centers, rural health centers, and Indian health services

14. “Final” Result, cont. • No cuts to health care benefits, maintained rehabilitative benefits • No provider tax increase • Maintains HCAF integrity • No transfers, no borrowing

15. “Final” Result, cont. • Micromanagement of health care delivery • OB Blended Payment Rate • Single rate for professional services for vaginal and c-section births to remove financial incentive and reduce c-section deliveries by 5% • Patient-Centered Decision Making • DHS will study making reimbursement contingent upon patient participation in patient-centered decision making process

16. “Final” Result, cont. • Micromanagement of health care delivery • Anesthesia management practices • Proposed elimination of payment for medical direction of CRNA • Final agreement: • Reduced management fee equal to CRNA payment • CRNAs may no longer be paid more than an MD in certain situations

17. “Final” Result, cont. • Micromanagement of health care delivery, cont. • Adverse Events Non-Payment • State will not reimburse for surgical errors or services billed by physician that caused an adverse event • Prior Auth for Imaging • DHS will require prior auth or use decision-making tool for non-emergency, outpatient imaging • Similar to current practice in private sector

18. “Final” Result, cont. • Micromanagement of health care delivery, cont. • Eligible Vendors/Peer Grouping • January 1, 2011 DHS will use the peer-grouping system in development by MDH • Effective January 2012 lowest 10th percentile cost/quality may not serve as a vendor for MA, GAMC or MNCare • Enrollment period each January if threshold is met • Unclear whether applies to state employees

19. Many, Many Other Physician Issues CME Required on Use of X-Ray Machines Non-payment for Adverse Events Imaging Prior Auth Blood Lead Level standard of care in statute Licensing Fee Increase Safe Patient Handling Pharmaceutical Gift Ban Mandatory Health Care Home Assignment Prior Auth for ADHD medications C-Section and VBAC policies Workers Comp Exclusive Provider List Restrictions on Rx data mining Cigarette Tax Increase Alcohol Tax Increase First-Dollar Preventative Coverage for HSAs Rural Cooperative anti-trust immunity Restructuring of state health care programs Standardized Formulary and Prior-Auth Exception E-health records Anesthesiology cuts APN Changes PE in Schools PA Licensing MNCare for unemployed Audiology licensing changes Psychologist licensing bill Chiro licensing bill Birthing centers Medical liability Genetic Privacy Billing Clearinghouses Autism Task Force Laser Safety False Claims Patient-Centered Decision Making Birthing Centers and OB Cut Primary Caries Prevention Cuts to Public Health Grants (SHIP) Standardized Tamper-Proof Rx pads Judicial authority to change death records Cap on medical records copy charges Health plan undoing of P4P standards Primary Seatbelt Child Passenger Safety (booster seats) Transparency of health plan payments Maintain integrity of HCAF Newborn Screening Body Art Licensing and Standards Colon Cancer Screening Pharmacist vaccine administration Point-of-service eligibility verification Loan forgiveness program expansion

20. Policy Provision Highlights • Health Plan Payment Disclosure • Health plans required to report expenditures to DHS • DHS will analyze and disclose aggregate payments by plan • Goal: more transparency and accountability

21. Policy Provision Highlights, Cont. • Safe Patient Handling • Clinics that move patients must have a plan for moving patients by July 1, 2010 • Plan must minimize manual lifting by direct patient care workers • Must address the following: • assessment of risks with regard to patient handling • the acquisition of adequate and appropriate equipment • training of direct patient care workers • A single plan for will suffice if more than one clinical setting

22. Policy Provision Highlights, cont. • Physician Assistant Oversight • Physicians may now supervise up to 5 PAs (up from 2) • Standardized Prior Auth and Formulary Exception Forms • MDH will develop standard electronic form to be used by all health plans • Significant administrative and cost savings for clinics

23. Policy Provision Highlights, cont • State False Claims Act • Creates state action similar to federal false claims act • Includes whistleblower incentives • Penalty for “knowingly” presents a false or fraudulent claim to the state • Will have to defend whether a billing error was done knowingly • Final bill amended to allow “right to cure” • Entity has been informed of false or fraudulent claim • Entity repays the actual damages within 45 days of being informed

24. Policy Provision Highlights, cont. • Primary Seatbelt • Beginning June 9, drivers can stopped if unbelted • Law also now applies to all passengers • Child Passenger Safety • Children under age 8, up to 4’9” tall, must be in booster seats effective July 1

25. Policy Provision Highlights, cont. Many others did not pass, including: • Medical Records Copy Fees • Cap charges for coping medical records for patients and attorneys at $.05/page or cost, whichever is less • Primary Caries Prevention • Require primary care providers to do basic dental exam and fluoride varnish at each visit

26. Policy Provision Highlights, cont. • Birthing Centers • Establish and license birthing centers • Create presumption for “normal” births to be delivered at birthing centers • Set equal payment for birthing center and hospital delivery • VBAC • Require all hospitals to perform vaginal birth after cesarean • APN Independence • Eliminated written prescribing agreement in exchange for written collaborative agreement, MNA bill with no collaborative agreement

27. 2009 Session Assessment • Painful, but could have been worse • Minimized impact of physician cuts • Growing knowledge of low public program reimbursement • Bi-partisan commitment to health care reform principles missing • Universal coverage vs. 35,000 eliminated from GAMC • Incentives for prevention vs. Uncompensated care pool • Payment reform vs. payment cuts • Public Health investments vs. SHIP unallotment?

28. A Peek at Next Year • Reaction to unallotment • Additional budgeting depending on economy • Continued pressure to implement health care reform faster and get more cost savings • Growing questions over use private health plans administering public programs

29. There Should Be No Doubt… • Legislative action affects your practice • How you run your clinic – record retention, privacy, taxes, fees, etc. • Reimbursement – state public programs • Scope of Practice • Professional liability policy – statute of limitations, award caps • Public health policy – tobacco, obesity, etc. • Who has access to care – eligibility for public programs • What our health care system will look like in the future • If you don’t get engaged, who will?

30. The MMA Needs You • Join, if you’re not a member • Email Action Alerts • Get to know your legislators • Day at the Capitol • Capitol Rounds • District Dialogues • Participate in MEDPAC

31. Questions?