October 13, 2003

 
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Governor Baldacci Announces Maine Quality Forum and Hospital Commission Appointments
Governor John Baldacci last week announced the appointment of 17 persons to serve on the Advisory Council for the Maine Quality Forum. He also announced the nine appointments to the Commission to Study Maine's Hospitals. Both of the groups were established earlier this year in the legislation that created the Dirigo Health Plan.

 Maine Quality Forum

         The Maine Quality Forum Advisory Council is a subsidiary of Dirigo Health and has broad responsibilities to establish and advise the Maine Quality Forum.  The Forum is intended to be a watchdog for quality of health care in Maine.  The Dirigo Health legislation calls upon the Forum to provide easy to understand information for Maine's citizens about health care quality and will establish benchmarks for the quality of care Maine citizens receive and measure the performance of the health care system against them.  The Forum also has responsibility to make determinations about what kind of technology Maine needs and what technology works most effectively to improve the quality of care.

     In making the appointments Governor Baldacci noted, "It is well known that it takes 10 to 15 years for best practices to become common practices in every health care provider's office and hospital.  The Maine Quality Forum will focus its attention on new research and other information to provide consumers the help they need in making health care choices and help providers continue to improve the quality of care Mainers now enjoy."

     Physician appointees to the Council include MMA President Maroulla Gleaton, M.D., Clifford Rosen, M.D. of Bangor, Janice Wnek, M.D. of Brunswick, Stephen Shannon,D.O.., Dean and Vice President for Health Services for the University of New England College of Osteopathic Medicine; Robert McArtor, M.D. of MaineHealth; Karen Bell, M.D.,  Medical Director of Anthem Blue Cross Blue Shield of Maine; and Laureen Biczak, D.O., Medical Director of MaineCare.  A complete listing of the 17 appointees follows this article.

Commission to Study Maine's Hospitals

Governor Baldacci announced on Oct. 9th nine appointments to the Commission to Study Maine's Hospitals.  The Commission, authorized in the Dirigo Health legislation, will work with the Governor's Office of Health Policy and Finance to report on hospital costs and services and to make recommendations for strengthening and rationalizing the delivery of hospital services statewide.  Physicians appointed to the Commission are Joshua Cutler, M.D. of Maine Cardiology Associates and Richard Wexler, M.D., Medical Director of Medical Care Development.  Drs. Cutler and Wexler were both nominated by the Maine Medical Association.  A full list of the Commission members appears at the end of this article.

The Commission will be chaired by William Haggett of Bath, Chairman of the Board and CEO of Naturally Potatoes and former CEO of Bath Iron Works.

COMMISSION TO STUDY MAINE'S COMMUNITY HOSPITALS

 

William Haggett, CEO, Naturally Potatoes, Chair

Scott Bullock, CEO, MaineGeneral Hospital

John Welsh, CEO, Rumford Hospital

Richard Wexler, M.D., Medical Director, Medical Care Development

Joshua Cutler, M.D., Maine Cardiology Associates

Joseph Ditre, Executive Director, Consumers for Affordable Health Care Foundation

Robert Downs, Harvard Pilgrim Healthcare

Christopher St. John, Executive Director, Maine Center for Economic Policy

Pat Philbrook, R.N., Executive Director, Maine State Nurses Association

 

MAINE QUALITY FORUM ADVISORY COUNCIL

 

Clifford Rosen, M.D.

Janice Wnek, M.D.

Stephen Shannon, D.O., Dean & V.P. for Health Services, UNECOM

Robert McArtor, M.D.

Richard Bruns, D.C.

Nancy Kelleher, Director of Governmental Affairs, Sweetser

Rebecca Colwell, V.P. of Home Care & Hospice, Healthreach Networks

Rebecca Martins

Jonathan Beal, Esq.

Lisa Miller, M.P.H., Senior Program Officer, The Bingham Program

David White, President, MDI Imported Car Service, Inc.

Frank Johnson, Executive Director, Maine State Employees Health Insurance Program

Daniel Roet, Director of Human Resources, BIW

Jim McGregor, E.V.P., Maine Merchants Association

Charles Morrison, President & CEO, Androscoggin County Chamber of Commerce

Karen Bell, M.D., Medical Director, Anthem Blue Cross and Blue Shield

Laureen Biczak, D.O., Medical Director, MaineCare

The AMA's Top 12 Fictions & Facts About Medical Liability Reform: #8
FICTION #8:  Even though California has some of the most restrictive damage caps in the country, between 1988 and 1998, medical liability insurance premiums in California rose 37%, compared to a nationwide average of 5.7%.

FACT:  The California rates went from $14,600 in 1988 to $20,000 in 1998.  A true statement, but highly misleading.  For one thing, it says nothing about what has happened with premium rates in California and other parts of the country since 1998, and in fact, that picture is vastly different.  Rates in California have been stable since 1998, while rates in most other parts of the country have escalated rapidly.  The 1998 data point was a practical abnormality - rates in California were no higher than $15,000 in any of the years during the eleven-year period, except for 1998.  The 1998 data point is also a statistical aberration as it was based on 125 responses with a standard of error of $5600.  On balance, and in consideration of more recent data, it is fair to conclude that rates in urban California are much lower than those of almost all other major urban areas in the nation.  The average California physician saved $14,900 in lower PLI premiums compared to the national average over the period 1988-1998.  [return to top]

AMA President Palmisano's Federal Liability Reform Update
Last Thursday, AMA President Donald J. Palmisano, M.D., J.D. published the following update on the national medical liability reform debate in the AMA's e-Voice.

The fight for medical liability reform continues as the Senate Republican leadership plans to proceed with specialty-specific medical liability reform bills.  The AMA is willing to support specialty-specific bills, but only if they are consistent with principles of MICRA, H.R. 5 and S. 11.

The first of a possible series of medical liability reform bills would focus on obstetrical services.  Unfortunately, S. 607 is under consideration as the "base" bill and it contains 3 items that would be detrimental to our policy.

First, it does not provide a flexicap, and thus would fail to protect states such as Indiana, New Mexico, and Louisiana, who have additional limits on damage awards.

Second, it contains troublesome subrogation language that would allow health plans to recoup from physicians and hospitals any payments made in case of alleged malpractice.  Not only does this language not follow MICRA, it would specifically undermine California's collateral source and subrogation language and any state that has followed it.

Lastly, S. 607 contains ERISA language that could reverse hard-fought court victories won by state and national medical societies and the AMA.  Opponents of medical liability reform would be at the ready with arguments about protecting HMOs at the expense of patients.

I've said it before and I'll say it again - - organized medicine needs to deliver a unified and consistent message.  If different groups are delivering even slightly different messages, our chances of obtaining medical liability reform are dramatically decreased. 

Please don't hesitate to contact me about this subject at Donald_Palmisano@ama-assn.org. [return to top]

HHS OIG Publishes FY 2004 Work Plan to Combat Fraud & Abuse
On October 1, the U.S. Department of Health & Human Services, Office of the Inspector General released its Fiscal Year 2004 Work Plan which you can find on the Internet (click on title).

The OIG's top priority this year will be investigating pharmaceutical fraud and drug pricing, but the OIG also will focus on the following physician Medicare billing practices:

  • Billing for physician consultation services (the program paid $2 billion for these services in 2000);
  • Physician evaluation & management coding (the program paid more than $23 billion for E&M billing in 2001);
  • Use of the -25 modifier (billing for an additional service unrelated to an E&M billing on the same date; the program paid $1.7 billion for such services in 2001);
  • Modifiers used to bypass the National Correct Coding Initiative edits (the program paid $565 million for such services in 2001);
  • ESRD monthly capitation payment relative value units;
  • Proper place of service codes for physician services provided in ASUs and hospital outpatient settings;
  • Face-to-face physician encounters where the physician and patient are separated by a long distance;
  • Billing for care plan oversight services (physician supervision services in home health or hospice settings; the program's spending for such services grew from $15 million in 2000 to $41 million in 2001);
  • Billing for diagnostic tests, particularly nerve conduction studies;
  • Billing the professional component of radiation therapy management services (proper billing is 1 billable unit for every 5 sessions of treatment);
  • Billing of services or supplies provided by allied health professionals "incident to" the physician (requires direct supervision by the physician);
  • Ordering of services or supplies by physicians excluded from the program.

If you have specific coding questions, please contact Laurie Desjardins, ldesjardins@thecodingcenter.org, or Jana Purrell, jpurrell@thecodingcenter.org, both of the Coding Center of the Maine, New Hampshire, and Vermont medical societies. [return to top]

MaineCare Preferred Drug List Saving $ -But at Who's Expense?
MMA representatives met last week with MaineCare officials to discuss the Preferred Drug List which became fully operational Oct. 1.  The Association had received many communications from members complaining about the PDL, the process of prior authorizations and poor communications from the Bureau.

Division of Quality Improvement Director Jude Walsh and Acting DHS Commissioner Peter Walsh heard the Association's concerns and agreed to convene a work group of physicians and MaineCare staff to work on improvements.  The Association acknowledges that a PDL is necessary if the program is to achieve the $100 annual savings from the drug program mandated by the Governor and the Legislature in the biennial budget.  But improvements must be made in the implementation of the program and in the communications with both MaineCare recipients and participating physicians.

The Bureau's contractor, Goold Health Systems, is now processing about 800 prior authorization requests per day.  While most are responded to within 24 hours, MMA brought to the attention of the Bureau several instances where the process was delayed.  In one notable case, a psychiatrist received approval 31 days after the initial request and after spending over 7 hours working the system.  Some physicians have become so frustrated by the process that a complaint has been filed at the Board of Licensure in Medicine, asking how a physician who has not examined a patient can be over-ruling the attending physician's recommendation  on drug therapy.  It is not yet clear whether the Board will review this interesting question.  Other physicians have expressed concerns about their own liability when a request is denied.

When a request for prior approval is denied, the physician has no appeal rights under existing law.  While the patient can appeal, there are few MaineCare patients with the wherewithal to do so.

The work group hopes to start work immediately.  if you are interested in serving, or would like to bring a case to its attention, please communicate with Gordon Smith or Andrew MacLean at MMA. (gsmith@mainemed.com; amaclean@mainemed.com) [return to top]

Congress Continues Work on Medicare Reform/Prescription Drug Coverage/Physician Payment Legislation
With a tentative adjournment scheduled for November, help ensure that Congress does not leave Washington this year without fixing the planned 2004 Medicare payment cut for physicians. Please communicate with the Maine Congressional delegation urging them to support the inclusion of the House provisions calling for a minimum 1.5% update for 2004 and 2005 in any final Medicare legislation.

Senators Olympia Snowe (202-224-5344) and Susan Collins (202-224-2523 ) play particularly important roles in the Senate and your call to them would be of assistance.  If this problem isn't fixed by Congress before it adjourns, CMS has announced a 4.2% reduction in physician payments, beginning January 1, 2004. [return to top]

Literature & Medicine Conference Oct. 25, 2003 at St. Mary's Regional Medical Center
The Literature & Medicine: Humanities at the Heart of Health Care program of the Maine Humanities Council is holding a day-long conference especially for health care providers on Saturday, October 25, 2003 at St. Mary's Regional Medical Center in Lewiston.

Attendees will explore the connections between literature, culture and health care with three nationally known writers and with colleagues from across New England.  The keynote speaker is Arthur Kleinman, a major figure in medical anthropology and cross-cultural psychiatry.  He is the Rabb Professor of Anthropology at Harvard University.  The author of, The Illness Narratives;  Suffering, Healing & the Human Condition and Patients and Healers in the Context of Culture, he is also a consultant to the World Health Organization and the 2001 winner of the Franz Boas Award of the American Anthropological Association.  His talk is titled, "Suffering, Culture and Care;  How the Moral Basis of Health Care is Threatened in Our Era."

Rafael Campo, a physician and poet, will speak about how literature has helped him better appreciate, reflect upon, and bridge, the often different life experiences of his patients.  Dr. Campo practices internal medicine at Beth Israel Deaconess Medical Center in Boston and teaches at Harvard Medical School.

There will also be a reading by Vaneta Masson who has practices as a registered nurse for thirty five years in community and hospital settings in the United States and abroad.

In addition to the three formal presentations, there will be small group discussions of a reading demonstrating how literature and discussion lead to better understanding of different perspectives. 

The $25 registration fee includes lunch and CME is available.  The conference is co-sponsored by St. Mary's Regional Medical Center and supported financially by the Maine Medical Association with additional support from the National Endowment for the Humanities, Cary Medical Center, Franklin Memorial Hospital, Maine General Medical Center, Maine Medical Center/Spring Harbor Hospital, Mayo Regional Hospital, MidCoast Hospital, Penobscot Bay Medical Center, and St. Joseph's Health Care.

To register for the conference or for more information about Literature & Medicine; Humanities at the Heart of Health Care, visit www.mainehumanities.org or call (toll free) 1-866-MEreader or 1-866-637-3233. [return to top]

Electronic Prescription Monitoring System Funded
The State Office of Substance Abuse has recently announced the receipt of a $300,000 grant from the federal Department of Justice, which will be used to establish a computerized record of narcotic purchases from every pharmacy in the state.  Legislation was enacted during the Legislative session earlier this year authorizing such a registry, but grant funding or private donations were required to fund it.  With the start-up funding intact, the registry is expected to be operational by July 2004.

The registry will flag unusual combinations of drugs and multiple purchases by the same patient and highlight suspicious activity.  Purchases which do meet the screens will be highlighted and the information sent to physicians who had prescribed one or more of the drugs.  The registry is expected to be updated weekly and reports generated on that basis.

The registry is not a tool of law enforcement.  Access to the information is restricted by law to prescribers, dispensers, medical licensing board authorities and personnel charged with administering the system. Patients will also be able to obtain their own information.

About 16 other states have such monitoring systems in place. [return to top]

MaineCare DUR Committee to Meet Tuesday, Oct. 14.
The MaineCare Drug Utilization Review Committee will meet on Tuesday, October 14, 2003 in Conference Room 1A & B at the Department of Human Services/Bureau of Medical Serices offices, 442 Civic Center Drive, Augusta, Maine, from 6:00 p.m. to 8:00 p.m.  A public comment period will begin at 6:00 p.m.  A preliminary agenda follows:

  1. PDL implemention update
  2. PDL - PA determination times
  3. Supplemental rebate updates
  4. Outstanding isues regarding PDL:
    • Review letters received regarding PDL and criteria.                                                                  
    • Discuss current status of GI, Diabetes provider education program.
    • Discuss definitions of terms used in PDL Program:  "Grandfather","Step Therapy", etc.
  5. Discuss next steps for PDL:
    • Bipolar disease/mmood stabilizer/anticonvulsant initiative
    • Dose optimization - using Wellbutrin 100 mg's instead of 200 mg
    • Wellbutrin XL - tentative non-preferred
    • TOBI-NEB - use Tobramycin/NaC1 components
[return to top]

For more information or to contact us directly, please visit www.mainemed.com l ©2003, Maine Medical Association