THE PHYSICIAN ADVOCATE MMA NEWS

tremely functional and shouldn’t duplicate what can be done elsewhere. If it’s meant to be an Expedia-like marketplace for peo- ple to buy policies, then it should group all policies that qualify and shouldn’t exclude some. That is a contentious point of debate. We’ve had meeting after meet- ing about the exchange. It is a huge topic

PHOTO COURTESYPHOTO REPRESENTATIVES OF HOUSE MN OF for legislators. If indeed Gov. Dayton is as good as his word and he wants to col- laborate and make the exchange as good as it can be, and the committee chairs do the same, it will be a reasonably decent bill.

On expanding Medicaid I question the affordability of expanding Medicaid. Times are different and legisla- tors on the left should pay more attention to the fiscally sensible course. I appreciate their sense of humanity; but at some point someone has to pay for all of this. I believe they are making promises they may not be able to keep with money they hope they can keep borrowing.

A FEW MINUTES WITH … Rep. Jim Abeler, clinician and legislator

BY MELISSA MRACHEK s a chiropractor, Rep. Jim Abeler On being in the minority party On the primary care (R-Anoka) knows a thing or two My phone rings a little less often now, so physician workforce Aabout adjustments. So, it shouldn’t I will be leading in a different way. I will The issue of not enough physicians is come as a surprise that when the Min- continue looking after the needs of the something the medical community needs nesota House of Representatives switched people and pushing for even better service to grapple with internally or the state will from Republican to Democratic control with the same or a little bit more money. grapple with it for them. It is best decided after last fall’s election, Abeler, a 14-year I’m looking forward to doing the best I can within the medical community because political veteran, took the change in stride. and offering advice when the committees physicians may not like the solutions the Although he may no longer be chair of will take it. state comes up with. The reality is we have the Health and Human Services (HHS) to get more physicians to choose to go into Finance Committee, Abeler still serves on On the health insurance exchange areas of need such as primary care. that committee as well as the HHS policy Republicans, as a group, aren’t The ACA does provide for higher Medi- committee. Through those groups, he fans of the insurance exchange. It’s part of cal Assistance reimbursement for primary will have a say about the health insurance the Affordable Care Act, which was passed care physicians for two years. But another exchange, expanding Medicaid and a num- 100 percent to none in terms of one side aspect of the problem is the glamorization ber of regulatory changes coming out of versus the other. Whenever you jam some- of specialty care and lack of interest in pri- the Affordable Care Act (ACA). thing through, it’s politically unpopular mary care. The future isn’t in having more The Physician Advocate sat down with and the quality of the bill deteriorates. I orthopedic surgeries or ophthalmologic Abeler to talk about the shift in power at want a Minnesota version of the exchange advances; the future is in keeping people the Capitol and what he sees as the biggest with as much local control as possible. So healthier and coordinating care at the issues for health care this year. I’m talking to others about ways to make it street level. We have physician assistants, better. I think the exchange needs to be ex-

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while physicians vacate it in favor of spe- those who really need the help. In simple cialties. terms, I would like to see MERC money directed more toward minority popula- On support for new physicians tions and certainly primary care. I tried to protect Medical Education and Research Cost (MERC) funding because On being a chiropractor it is necessary to support up-and-coming and a legislator physicians. I also tried to reform the pro- I’ve been practicing chiropractic care for

PHOTO COURTESYPHOTO REPRESENTATIVES OF HOUSE MN OF gram to make it more focused on minority 34 years. During that time, I have made a physicians so they could deliver more cul- lot of connections with people who have turally competent care to minority popula- helped me in my role as a legislator. Hope- tions. Unfortunately, I was unsuccessful. fully, my perspective can help with much- There are real health disparities be- needed health care reform, so we are able tween our Hispanic, Native-American and to better serve people in Minnesota. African-American populations and the I also hope private physicians will en- Rep. Jim Abeler juggles his legislative duties with general population. It’s on my mind. As a gage more with legislators. Physicians are running a chiropractic practice in Anoka. policymaker it is my job to worry about very bright, respected and have expertise. all 5.3 million Minnesotans, not just the If they would reach out and talk to their nurse practitioners, community health 38,000 in my district. It’s a policy issue legislators, it would greatly help as we workers, even community paramedics about which the MMA could provide form policy. moving into the world of primary care, guidance and leadership and reach out to

RIGHT: New LSMS MMA in action President Jay Knuths, M.D., In late January, Dan Maddox, M.D., MMA president, Terry Ruane, MMA (right) receives director of membership, marketing and communications, and Brian Strub, the ceremonial sledgehammer manager of physician outreach, attended the Lake Superior Medical Society from George STRUB BRIAN BY PHOTO (LSMS) annual meeting in Duluth. At the meeting, the LSMS installed Jay Apostolou, M.D. Knuths, M.D., as its new president. Maddox discussed governance changes, the MMA’s planned listening sessions and policy forums, the MMA’s legisla- tive priorities and the MMA Foundation. Dave Thorson, M.D., MMA board chair, and Robert Meiches, M.D., MMA CEO, testified before separate committees at the Capitol in support BELOW: Robert Meiches, M.D., MMA CEO (left), of Medical Assistance expansion. testifies on behalf of Strub Juliana Milhofer Medical Assistance and , MMA policy analyst, met with Tamiko expansion. Here, he sits Morgan, M.D., and Andrew Kiragu, M.D., of the Minnesota Association of next to the bill’s author Rep. Thomas Huntley Black Physicians to discuss membership, listening sessions, policy commit- (DFL-Duluth). tees and other ways physicians can become more involved with the MMA. Janet Silversmith, MMA director of health policy, discussed Minnesota’s health insurance exchange effort at a meeting of the Shakopee Rotary (by invitation of a Shakopee physician) in early HAUSER DAN BY PHOTO February. Meiches, Silversmith and Dave Renner, MMA director of state and federal legislation, met with the Minnesota Department of Health’s Health Policy Division Director Diane Rydrich and Health Economist Stefan Gildemeister in February to discuss key projects including provider peer grouping and the MMA’s legislative priorities.

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While waiting for their legislators to become available, xxx, George Apostolou, M.D. and Robert Nesheim, M.D., talk in a Capitol hallway.

Dave Renner, MMA director of state and federal legislation, addresses physicians, residents and medical students before sending them to meet with their legislators.

Christopher Wenner, M.D., a solo practitioner in Cold Spring, meets with While waiting for their legislators, Jake Prunuske, M.D., (left) George Sen. Michelle Fischbach Apostolou, M.D. and Robert Nesheim, M.D., converse in a Captiol corridor. (R-Paynesville). ALL PHOTOS BY STEVE WEWERKA White coats take over Capitol for a day

Physicians, residents and medicals students from across Minne- sota gathered February 7 for the MMA’s Day at the Capitol event. The annual event provides an opportunity for physicians to meet face to face with their state legislators and to network with each other.

Rep. (DFL-St. Paul), House Majority Leader, Rep. Erin Murphy (DFL-St. Paul), answered questions posed by those in attendance on a variety of House Majority Leader, discussed a variety of health care topics during a issues from the expansion of Medicaid to the creation of a Minne- 20-minute Q&A with physicians. sota-based health insurance exchange.

Lisa Erickson, M.D., a board member of MEDPAC, the MMA’s political action committee, addresses members Medical students watched a brief House floor session during Day at after Day at the Capitol while Eric Dick, the MMA’s the Capitol. They include (from left): Ann Bergstrand, Mike Kalinoski, manager of state legislative affairs, looks on. Courtney Moors, Thomas Baron and Eric McDaniel.

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Where there’s smoke … raise the price

early one out of five Minnesotans still up smoking, encourage adults to quit and

smoke despite the millions of dollars reduce smoking-related health care costs. WEWERKA STEVE BY PHOTO Nspent on advertising and PR cam- We further support using the added Dan Maddox, MMA President paigns to get them to quit. And although tax money from tobacco to help fund the anti-tobacco messaging has been every- Medical Education and Research Cost where you look—on billboards, in the (MERC) fund and the Statewide Health Studies show that skyways, on buses—for some time, 625,000 Improvement Program (SHIP). Both have Minnesotans still smoke and 6,800 Minne- suffered drastic budget cuts in recent the best way to deter sota kids become smokers every year. years. Smoking is obviously still a problem—a Established in 1996, MERC was created young“ people from big problem. In Minnesota, tobacco use to help teaching hospitals and clinics offset is responsible for more than 5,100 deaths a portion of the costs of clinical training. beginning to smoke each year, and tobacco use results in nearly MERC has been funded by three principal $3 billion in health-related costs every means: a portion of the state’s cigarette and encourage adults year. tax; a percentage of state spending under Telling people to stop isn’t enough. the Prepaid Medical Assistance Program; to quit is to hit them in Rather, studies show that the best way to and the federal deter young people from beginning to matching funds that come through trans- their wallets. smoke and encourage adults to quit is to fers and other mechanisms. We’d like to hit them in their wallets. A 10 percent see an even larger portion of the tobacco increase in the price of cigarettes has been tax go to re-fund (and possibly increase schools are working with local farmers shown to reduce the number of young funding for) clinical training. to bring fresh produce” to lunchrooms so people who start smoking by 6.5 percent. The need for clinical training has never students can eat better. SHIP allows local That’s why increasing the tax on cigarettes been greater. The United States already has communities to determine which things and other tobacco products is one of the a shortage of physicians, in particular pri- they can do to help their residents live MMA’s top priorities for the 2013 legisla- mary care doctors. And with the Afford- longer and healthier lives. Let’s keep these tive session. An increase of $1.50 per pack able Care Act, more people will have ac- programs strong. would convince more than 30,000 Min- cess to health care and thus need doctors. So let’s do it. Let’s raise the price of to- nesotans quit and prevent 41,200 fewer MERC funding was cut in 2011. We need bacco, which will prevent kids from start- Minnesota children from smoking into not only to reverse that cut but expand ing and encourage adults to stop smoking. adulthood. funding of the programs that will train the And let’s use the money we collect to fund Minnesota currently taxes tobacco at next generation of doctors. medical training and prevent chronic con- $1.23 per pack, which puts us at 28th in Funding SHIP is a cost-effective in- ditions. Sounds like a multiple-win to me. the nation in terms of how much we tax vestment in the health of Minnesotans. cigarettes. By increasing the tax on to- Through SHIP, the Minnesota Department bacco, we will prevent kids from taking of Health works with communities to help them reduce the burden of chronic disease, particularly by preventing obesity and tobacco use. For example, through SHIP,

MARCH 2013 | MINNESOTA MEDICINE | 29 THE PHYSICIAN ADVOCATE MMA NEWS

News briefs MMA makes a case for expanding billion over the next two biennia. Under “little cigars” are classified. Little cigars Medical Assistance the Affordable Care Act, the federal gov- are flavored products often marketed to The MMA’s board chair and CEO testified ernment will pay 100 percent of the cost of youths. before House and Senate committees in the expansion for new enrollees during the Currently, because of a tax loophole, January regarding the expansion of Medi- next two years; the feds’ contribution will they are less expensive than cigarettes, cal Assistance (MA), Minnesota’s version be reduced to 90 percent after that. Cur- even though they are nearly identical to of Medicaid. rently, Minnesota and the federal govern- them. In mid-February, both the House and ment share the costs of Medicaid 50/50. In late January, Sens. the Senate passed legislation expanding the (DFL-) and (R- program to adults with annual incomes up Rochester) introduced similar bills that to 138 percent of the federal poverty level. would reclassify little cigars as cigarettes. Gov. Mark Dayton quickly signed it into “These little cigars are very appealing to law. youths,” says Eric Dick, the MMA’s man- The MMA made MA expansion a 2013 ager of state legislative affairs. “They need legislative priority. However, it remains to be taxed and treated like cigarettes so concerned about other related issues. kids are discouraged from buying them.” “The long-term sustainability of the Medical Assistance program requires Governor the state to adequately pay for physician proposes services provided to Medical Assistance restoring enrollees,” MMA Board Chair Dave Thor- Move to increase the tobacco tax MERC, SHIP son, M.D., told the Senate’s Committee on gains footing funding Health, Human Services and Housing at a Another MMA legislative priority—in- In his proposed January 30 hearing. “Minnesota physicians creasing the amount tobacco products are budget, Gov. have had their fee-for-service rates frozen taxed—gained momentum at the Capitol Mark Dayton PHOTO COURTESYPHOTO OFFICE GOVERNOR’S MN OF for 13 years,” he said, pointing out that early in the session. (See Viewpoint on recommends Minnesota currently ranks 47th out of 50 page 29.) restoring fund- states on its MA fee-for-service payment Several lawmakers introduced bills that ing to the Med- Gov. Mark Dayton rates for physicians. would significantly increase the tax. Cur- ical Education and Research Cost (MERC) The week before, MMA CEO Robert rently, Minnesota ranks 28th out of the program back to $49.5 million, the level at Meiches, M.D., shared similar comments 50 states in terms of how much it taxes which it was funded prior to budget cuts with the House Health and Human Ser- tobacco. in 2011. vices Policy Committee. Despite the stag- In addition, Gov. Mark Dayton sug- MERC dollars are used to fund clinical nant rates, Minnesota physicians continue gested upping the ante on tobacco as training for medical students, residents to fully participate in the program. “Physi- part of his proposed budget, calling for a and students in other health professions. cians care about their patients; they want 94-cents-per-pack increase to the cigarette Dayton also called for re-funding most of to serve,” Meiches said. tax. This is a departure for the governor the State Health Improvement Program According to the Department of Human who in the past has voiced his dislike of (SHIP). Funding for SHIP was cut as part Services, increasing MA to 138 percent increased taxing on tobacco, calling it too of the 2011 budget agreement. Dayton of the federal poverty level will provide regressive. wants to see an investment of $40 million coverage to 87,000 Minnesotans. Min- “We like what we are seeing in terms over two years. nesotaCare already covers 53,000 of those of the tobacco tax,” notes Eric Dick, the “We are pleased with many aspects of people; 34,000 are currently uninsured. MMA’s manager of state legislative affairs. the governor’s proposed budget,” says Dave Those covered by MinnesotaCare will see “Study after study has shown that raising Renner, MMA director of state and federal better coverage for less cost by switching to the price on tobacco deters youths from legislation. “He is recommending provid- Medical Assistance. starting and gets adults to stop smoking.” ing health care access to those who do not In addition to providing more Minne- have it currently. He’s also proposing an sotans with access to care, the expansion Little cigars legislation introduced increase in Medical Assistance payment is expected to save the state more than $1 Along with increasing the tobacco tax, rates to physicians and other providers, the MMA is advocating for changing how as well as increasing funding for medical

30 | MINNESOTA MEDICINE | MARCH 2013 MMA NEWS THE PHYSICIAN ADVOCATE training. These are three of the MMA’s leg- islative priorities for the session.”

Health insurance exchange on a RENNER DAVE BY PHOTO fast track On the first full day of the 2013 session, Sen. Tony Lourey (DFL-Kerrick), with bipartisan support, introduced SF 1, which would create a Minnesota-based health in- MMA President-Elect surance exchange. Since then, the bill has Cindy Firkins Smith, wended its way through a series of com- M.D., and President Dan Maddox, M.D., mittee hearings. A similar bill has been in- await members of Sen. troduced in the House (HF 5) by Rep. Joe Amy Klobuchar’s staff in Washington, D.C. Atkins (DFL-Inver Grove Heights). The exchange bills are on the fast track because a final version must be approved by both the House and the Senate and signed by the governor before March 31 to meet a deadline imposed by the Centers char (D), Rep. Betty McCollum (D), Rep. Expanded task force continues to for Medicare and Medicaid Services. John Kline (R) and Rep. Tim Waltz (D). examine MMA governance Although Lourey’s bill was introduced The MMA group asked the lawmak- The task force that will dissect, and po- with bipartisan support, Republicans have ers to finally fix the SGR problem, increase tentially rebuild, the MMA’s governance taken issue with several provisions: the the cap on the number of residency slots model began meeting in January—and overall cost to run the exchange’s board, funded through Medicare, avoid fur- with a few more members. the 3.5 percent health plan assessment that ther cuts to graduate medical education The group, which is being referred to as would fund the exchange and the board’s funding, and reauthorize funding for the Governance 2.0, takes its direction from role as the “active purchaser.” Lawmak- National All Schedules Prescription Elec- the 2012 House of Delegates resolution ers must decide whether they want the tronic Reporting (NASPER) program to to “continue its discussion of the recom- exchange to have an “active purchaser” help fight prescription opioid addiction, mended model for a new governance model, which means the exchange would abuse and diversion. structure as developed by the Governance only include qualified health plans, or a “The AMA meeting was a valuable Task Force and approved by the Board “clearinghouse” model, which means it meeting for the MMA,” Smith says. “It of Trustees and Executive Committee, in would include all insurance products that provided us the chance to meet one on order to gather more member input on the meet modest criteria. one with our members of Congress and proposed model and further define the Meanwhile, the MMA is advocating let them know how SGR is impacting our details needed for full implementation.” that the final version of a bill allow for practice. The good news is they were very “If the MMA plans to change its gover- physician involvement on the exchange’s responsive and agree it is time to stop this nance model, then we need to ensure that board. flawed funding formula.” our members understand it and are com- “Members of the Minnesota congressio- fortable it will provide them with input on MMA officials go to Washington nal delegation have been very supportive future public policy development,” says MMA President Dan Maddox, M.D., and of MMA issues and are more optimistic MMA President Dan Maddox, M.D. President-Elect Cindy Firkins Smith, than ever that we may be able to repeal The expanded task force includes more M.D., were in Washington, D.C., in Feb- SGR,” says Dave Renner, MMA direc- members from Component Medical Soci- ruary to attend an AMA meeting and tor of state and federal legislation. “The eties. It will meet three to five times dur- discuss the sustainable growth rate (SGR) new CBO estimate for the 10-year cost of ing the first quarter of 2013 with the goal and other health care issues with several eliminating SGR is helping our argument. of providing a final report to the MMA members of Minnesota’s congressional That cost has dropped more than $120 board in May. Its recommendations will delegation. billion.” Renner says the House Ways and eventually go to the 2013 House of Del- Maddox, Smith and MMA staff met Means Committee has developed an out- egates for action. with Sen. Al Franken (D), Rep. Erik line of principles to replace the SGR that Paulsen (R), Rep. Collin Peterson (D) and appear consistent with the MMA’s policies. staff from the offices of Sen. Amy Klobu-

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Task force members include: MMA launches podcast submit by fax to the department. You can • Ken Kephart, M.D., Twin Cities Medical In an effort to engage and inform Min- find the form at https://edocs.dhs.state. Society (chair) nesota physicians about timely topics, the mn.us/lfserver/Public/DHS-5211-ENG. • Beth Baker, M.D., Twin Cities Medical MMA has launched “The MMA Podcast” The MMA urges physicians to complete Society on its website and on iTunes. this by April 1. Submission of the attesta- • Juan Bowen, M.D., Zumbro Valley MMA staff will regularly add new tion form by that date ensures that eligible Medical Society podcasts dealing with issues important to services provided since January 1, 2013, • Stuart Cox, M.D., Twin Cities Medical MMA members. The first six podcasts ad- will be paid for using the enhanced rates. Society dress the MMA’s legislative priorities for For attestation forms submitted on or after • Don Jacobs, M.D., Twin Cities Medical the 2013 session. April 1, 2013, the enhanced rates will only Society “This is a great way to communicate apply to services effective the first of the • Fatima Jiwa, M.D., Twin Cities Medical with our members who are always on the month in which the form is received by Society go,” says Terry Ruane, the MMA’s director DHS. • Paul Matson, M.D., Blue Earth County of membership, marketing and commu- The enhanced rate will be the higher of Medical Society nications. “Members can subscribe to the a) the Medicare Physician Fee Schedule • Robert Moravec, M.D., MMA Speaker podcast through iTunes and listen on their rate in effect for the year in which the of the House phone, tablet or computer.” service was performed (either the 2013 • David Sprout, M.D., Lake Superior Members also can listen to each podcast or 2014 Medicare Physician Fee Schedule Medical Society online at www.mnmed.org/publications/ rate) or b) the rate using the Relative Value • Rahul Suresh (medical student), Zum- TheMMAPodcast. Unit for the calendar year in which the bro Valley Medical Society service was performed, multiplied by the DHS sets Medicaid payment 2009 Medicare conversion factor. If the rates for primary care physician’s submitted charge is lower than In January, the Minnesota Department of either of the applicable Medicare rates, the Human Services (DHS) announced plans physician’s submitted charge will be paid. for implementing an Affordable Care Act Final guidance for Medicaid managed provision increasing Medicaid payment care compliance with the enhance pay- rates for specified services provided by ment rates is expected soon. The MMA primary care physicians between January will provide its members with details as 1, 2013, and December 31, 2014. they are released. Services eligible for the enhanced pay- ment include Evaluation and Management MMA (E&M) codes 99201-99499 and vaccine members administration codes (90460-90461 and making a 90471-90474). difference State unveils new website To be eligible for the enhanced reim- Kenneth Flowe, to explain exchange bursement, physicians must first self-attest M.D., chief The State of Minnesota has unveiled a new that they practice family, general internal medical officer website that provides information on the or pediatric medicine. As part of that at- for Rice Memo- health insurance exchange’s progress. testation, they must specify that they are rial Hospital in The website includes a video on how the board-certified in one of those eligible Willmar, has exchange will work, a calculator that helps specialties or subspecialties and/or that 60 been named a individuals and small employers figure out percent of their Medicaid claims for the Kenneth Flowe, M.D. Fellow of the what they qualify for, and news about the prior year were for the E&M codes eligible American College of Hospital Executives. exchange’s creation. In addition, visitors for enhanced payment. Both fee-for-ser- It represents the highest achievement can submit questions they have on the ex- vice and managed care claims are included of professional development in health change. Find the site at www.mn.gov/hix. in the calculation of the 60 percent criteria. care management. Only 8,500 people are For physicians enrolling in Medical As- named as fellows. sistance for the first time, 60 percent of all Frederick Townsend, M.D., F.A.C.P., of billings in the previous month must have the Sanford Health Broadway Clinic in Al- been for the covered services. exandria, has been elected a Fellow of the DHS has developed an attestation form American College of Physicians. that eligible physicians must complete and

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