Minnesota has recently become a national hotspot in the battle over health care reform. Pushed by employer groups, state agencies, and health plan providers, Minnesota House Republicans proposed legislation mandating the adoption of “best practices” as a cost-containment strategy in January. Senate Democrats offered their own version of the measure, and Republican Governor Tim Pawlenty blessed the notion early on.
Minnesota citizens responded to the best practices proposal with a large stack of petitions opposing it. The governor refused to budge, and in late June he signed HF 2277, a Department of Human Services (DHS) licensing bill into which the “best practices” mandate was placed. But it’s clear the battle is not over.
Use of Force
Mandating “best practices” is not a new idea for Democrats. President Clinton included it in his failed health care plan 10 years ago, and state and federal proposals for government-defined “best practices” in medicine are popping up around the country.
Under an early version of the Minnesota plan, physicians who followed government-issued best practices would be protected from certain medical malpractice allegations. This didn’t sit well with attorneys in the Republican caucus, however, and the proposal was dropped.
Nonetheless, the governor made it clear early in the 2004 session that best practices would be his key health care strategy. In his State of the State address, Pawlenty said he would “force health care providers to use best practices.” A week later, Rep. Fran Bradley (R-Rochester), chair of the Health and Human Services Finance Committee and author of the cost containment bill, amended his bill to include a new best practices provision. No public testimony was allowed during consideration of the amendment.
The new provision authorizes state health officials to work with an HMO-funded group to create and distribute statewide a list of “best” medical practices. Physician adherence to the list is to be tracked, monitored, and publicly reported. To bring physician behavior in line with government treatment protocols, state agencies responsible for state employee health insurance and Medicaid would be permitted to withhold partial payment from providers who do not comply.
What started out as a simple little bill eventually had 60 amendments attached to it. The House and Senate Health and Human Services omnibus bills never made it to a conference committee because the two bodies could never agree to an overall state budget. As a result, at the 11th hour and without any public notification, the legislative leadership decided to use HF 2277 as the vehicle to get a package of health care bills into law.
Parts of bills or entire bills were added to it over a period of about eight hours. At the beginning of the meeting, the chair of the conference committee for HF 2277 announced, “amendments you have seen and amendments you haven’t seen are going to be added to this bill.”
“Coercion, Pure and Simple”
Things got nasty and personal during the conference committee process. To maintain caucus support for the provision, Bradley sent to all House members an email with disparaging comments about Twila Brase, a registered nurse and president of the Citizens’ Council on Health Care (CCHC), a free-market health care policy organization that opposed the bill. After CCHC received a copy of the email, Brase responded to each allegation, published Bradley’s comments and her response on the CCHC Web site, and issued a news release to the media and legislature. Bradley offered no response.
“[The push behind the proposed plan] is coercion, pure and simple,” says Brase. “The Minnesota public remains relatively uninformed. Major print media attending CCHC’s press conferences refused to report on the public’s opposition, and Republican leadership tried to prevent negative public testimony from becoming part of the public record. CCHC was regularly informed by policy committees that no public testimony would be taken on the ‘best practices’ section of the bill,” she said.
To overcome the freeze on discussion of the plan, CCHC launched a citizen petition campaign. A physician petition was added after the Minnesota Medical Association (MMA) testified in support of best practices, and CCHC discovered the organization had not surveyed its membership or even informed them of the plan. In less than two weeks, CCHC had 100 signed physician petitions.
The MMA’s support for the bill proved damaging to the opposition during the House floor debate. Rep. Mark Olson (R-Big Lake) held up a cookbook, called best practices “cookbook medicine,” and offered an amendment that would have stripped out the “best practices” provision. In response, Bradley cited the MMA endorsement as proof 9,000 physicians had no problem with the proposed legislation. The Olson amendment failed.
Individual physicians and citizens, however, expressed big problems with the plan. On May 13, CCHC staff and a group of citizens carried stacks of petitions into the Office of the Governor. Photos were taken–an action that later proved invaluable.
Two days later, without any public notification, legislators tacked the best practices provision onto HF 2277, the DHS licensing measure, late in the evening on the last day of session. A June 30, 2006 expiration date for the best practices mandate had been added. In the wee hours of the morning, shortly before the legislature adjourned for the year, the bill passed both chambers.
“The legislature has decreed that the practice of medicine must be centralized and controlled by bureaucrats in bed with HMOs. The expiration date is a facade intended purely as political cover,” said Brase. “During this election campaign, legislators wanted to be able to tell their constituents that ‘best practices’ is only temporary. They have no intention of backing off this proposal.”
CCHC turned its attention to Pawlenty, who had yet to sign the bill. To Brase’s surprise, Pawlenty’s senior policy analyst said she had never received the CCHC petitions, didn’t know where they were, and wasn’t sure the governor knew about them.
Lost and Found
To bring attention to citizens’ concerns in the matter, CCHC placed the petition delivery photo online, notified the governor’s staff of the Web site URL, and asked them to find the petitions. Less than 45 minutes later, the governor’s staff called CCHC to say the petitions had been located and taken into the governor’s office for his consideration.
Despite the opposition, Pawlenty signed the bill into law soon thereafter. Within three weeks, the Minnesota Department of Health announced plans for a state Web site to report physician adherence, and Pawlenty announced the formation of a Governor’s Health Cabinet focused on implementing best practices.
Meanwhile, physicians who are becoming aware of the law have threatened to drop out of the MMA, and delegates at the State Republican Convention added their opposition to best practices to the state party’s platform.
Although the Minnesota best practices law is in force at least temporarily, much opposition has been aroused, and it appears the notion stands on increasingly shaky political ground in the state. As similar battles pop up in other states, both supporters and opponents of “best practices” will find an interesting arsenal of battle strategies in the struggle in Minnesota.
Conrad F. Meier is managing editor of Health Care News. His email address is [email protected].
For more information …
Visit the Web site of the Citizens’ Council on Health Care, http://www.cchc-mn.org.