May 9, 2005

 
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Medical Liability Reform Bills Tentatively Scheduled for Friday, May 13
MMA and the Coalition for Health Care Access & Liability Reform urge you to discuss your concerns about our medical liability system with your legislators and to plan to attend the public hearing this coming Friday, May 13, at 9:30 am at the State House.
The Judiciary Committee will hold a day of public hearings on the medical liability bill offered by the Coalition for Health Care Access & Liability Reform (L.D. 1378) and bills offered by the Maine Trial Lawyers Association on Friday (5/13), beginning at 9:30 a.m. at the State House. If you are able to attend, please let Charyl Smith at MMA know (622.3374 or csmith@mainemed.com). 

You can find contact information for members of the Judiciary Committee on the web at:  http://janus.state.me.us/house/jt_com/jud.htm.

The following are talking points on medical liability reform:

  • Medical liability remains a top concern of Maine’s physicians (and physician assistants, dentists, podiatrists, chiropractors, and virtually all of Maine’s health professionals).Premiums are going up significantly because of an increasing amount of dollars being paid out per claim
  • The $250,000 limit on non-economic damages is the same amount as the limit in California, enacted more than 20 years ago. Numerous studies have established that a reasonable limit on non-economic damages is the most effective legal reform in terms of moderating premiums.
  • The vast majority of Maine physicians are insured by mutual insurance companies, which operate more like self-insurance than for-profit commercial companies. A mutual company is owned by its policyholders. If too much premium is collected in a year, the money is refunded to the policyholders through a dividend or credit.
  • A reasonable liability climate in Maine is essential in recruiting and retaining physicians. Maine continues to have a serious shortage with the ratio of physicians per one thousand patients being significantly below the national average.
  • Serious access problems are occurring in high-risk specialties such as neurosurgery, trauma, and obstetrics. A combination of high insurance premiums and low reimbursement in Maine threaten these specialties. Liability reform is essential if Maine is to remain attractive to physicians and other health professionals.
  • As other states enact meaningful reforms (recently the states of Texas and Georgia enacted caps on non-economic damages) these states will become more attractive to practice in and Maine will fall further behind.
  • Non-economic damages, the so-called “pain and suffering” part of a verdict are inherently unquantifiable and are awarded inconsistently. The result is a lottery system that makes insuring against these losses an unpredictable business.
  • Ultimately, consumers (patients) and employers pay the cost of medical liability premiums, and they cannot afford to pay more than all of the economic loss plus a quarter of a million dollars.
  • Liability risk leads to the wasteful practice of “defensive medicine” where additional tests and procedures are conducted primarily out of concern for the liability risk if the test or procedure isn’t done. The costs associated with defensive medicine are difficult to calculate, but have been estimated at approximately $50 billion a year nationally.
  • LD 1378 gives Maine a chance to avoid a full-blown crisis. Twenty states are in crisis and another twenty-five, including Maine are showing warning signs. As any legislation passed will impact only cases filed alleging negligence in care after the effective date of the law, and because it takes five to seven years to get to a jury, enactment is essential now in order to begin the move to an improved climate.
  • The medical liability problem threatens the ability of the health care community to improve quality because the system makes the decision to come forward to disclose errors more difficult.
  • The influence of the medical liability crisis upon future generations of physicians is of great concern. In March 2004, the American Osteopathic Association surveyed osteopathic medical students to determine the impact of the crisis upon their career decisions. The results were startling. Eighty-two percent stated that the crisis would influence the type of practice they would pursue while eighty-six percent stated that it would influence practice location. Ninety-eight percent indicated that they were very concerned about the medical liability crisis.
  • The citizens of Maine strongly support this type of legislation. More than three quarters of Mainers indicated in a public opinion survey less than two months ago that they were supportive of the bill with over fifty percent strongly supporting the legislation.

MECMS Update May 5, 2005
System and Interim payments:

System Payments

Claims paid on 04/22/05 and 04/27/05

Claims paid on 04/29/05

# providers paid through system

2,452

2,344

# claims processed in the system

245,104

233,716

# claims paid through system

110,560

108,218

amount paid through system

$39,616,135

$20,413,264

claims paid as percent of processed

45.11%

46.3%

Note: Claims processed in the system are released for payment by EFT on Friday and checks are mailed on the following Monday.Payments for the first week were processed in two batches.The amount paid through was much higher due to increased claim volume from processing backlog and higher dollar value claims

Interim payments

Payments for 04/26/05

Payments for 05/03/05

# providers paid interim payment

1,208

1,210

amount paid interim

$10,929,872

$10,830,703

Note:  Interim payments are released for payment by EFT on Tuesdays and checks mailed on Wednesday. 

 

Stabilization metrics

CNSI Responsibility

Claims volume processed. System capacity to process all claims loaded within one week cycle with a backlog of less than 20,000 claims no older than two weeks.(Processed is defined as an adjudicated claim with a status of paid, suspended, or denied.)

Claim processing duration. Average time from receipt of claim file from the provider to mailing of the check and remittance advice – 12 days.

Status:The system is now processing clean claims within this timeframe. These metrics will be removed from the report in future weeks, but will be monitored and reported if necessary.

System defects resolved. Resolve the March 15thbaselined defect list.Provide adequate resource contingency to resolve additional emergency defects within the constraints of the contingency period.Emergency defects are defined as:

  1. a defect that prevents the system (MECMS) from processing claims; i.e., system, database or network failure.
  2. A functional defect for which no workaround exists that results in over 5% of total claims processing improperly (or claims processing of a critical provider group(s) as determined by the Steering Committee)
  3. A defect that compromises the ability to meet state or federal financial/audit requirements.

Status:Over 50% of the emergency baselined defect list is implemented or in final test.A number of additional defects in the system have been identified since the list was baselined.Work on defects continues daily.

Backlog. Of unloaded claim files and unprocessed claims cleared by May 24th. Process all backlog in the system as of April 8 to reach the claims processed metric in #1 above. 

Status:Backlog claims in the system have been processed. This metric will be removed from future reports.

State Owner Responsibility

Data cleanup. Resolve major provider file and permissions matrix issues within 30 days including a process to make ongoing updates within 5 days.

Status:The permission matrices being analyzed by Deloitte and their report will be completed this week.Provider file clean-up is progressing, most notable is the progress made on updating provider licensing information.

CNSI/State Shared Responsibility

Suspended Claims.Reduce suspended claims with review of billing instructions and outreach to providers.

Reduce active suspended claims in the system to <40,000

Status:Suspended claims volume in the system remains at over 300,000 claims and has stabilized at that level..The priority is on first correcting defects that will reduce the suspended rate for new claims which will then improve the recycling of currently suspended claims.The project team is implementing a weekly plan to schedule implementation of system fixes and claims recycle to reduce the suspended claims.

Paid claims volume. Increase paid claims volume through resolution of system defects, reduction of suspended claims, and data clean-up.Increase paid claims volume to 60% of processed claims.

Status:Processed claims are paying at approximately 50%

Telephone System update

For the weeks ending April 25th, the Public Consulting group (PCG) Inquiry Unit received approximately 2,145 calls.Of those calls 2,000 were answered by the person receiving the call.The other 145 had to be referred to other BMS staff to answer the providers’ questions.BMS Inquiry during the same time period received approximately 1,780 calls from providers.

Since we last reported to you the BMS and PCG staffs have had training on the commonly asked questions that were not being answered previously. The staffs have received training on using the Track-It program, customer tracking software.In addition Beth Ketch and Brenda McCormick are assigning staff to research common questions that have proven difficult to answer.They established a “Fact Sheet” that is updated constantly and distributed throughout the office to better assist the staff with provider questions.

At the time of my last report several members of the Committee had reported that providers were unable to leave voice mail messages for their Provider Relations Specialist.We have made several adjustments to the telephone system and Beth Ketch has mandated that staff must check and empty their voice mail daily.We have made a number of test calls and it appears the changes have corrected the problem.

Through constant monitoring of the telephone system and quality checks on the answers provided by the staff, Beth Ketch and Brenda McCormick the managers of the two call centers will continue to design training to improve efficiency and accuracy by the staff.

The Governor’s Advisory Committee is meeting later today and DHHS’ Technical Advisory Committee tomorrow.

Other Key Points

  • Transfer of operations plan is progressing.A staggered transition is planned.Added state IT staff positions have been identified to support the transfer.
  • Enhanced Voice Response System development planned for late June.The implementation was delayed two weeks for finalization of call flows.

New Schedule for Interim Payments

The Department is moving the schedule for interim payments back by one business day in order to improve the accuracy of the calculation. Interim payments that would have been processed on Friday, May 13 will instead be processed on Monday, May 16. Providers will receive their interim electronic funds transfer (EFT) or paper checks one business day later.

This information was sent electronically to providers on Friday, April 29. It was also included in the provider update to be mailed on May 3.

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NHIC Offers Teleconference May 26, 2005
Ask the Contractor Teleconferences (ACT)

Ask the Contractor Teleconferences are similar to the Open Door Forums offered by the Centers for Medicare & Medicaid Services (CMS). They serve to identify problems, respond to questions in a timely manner, provide methods of sharing information, and are an excellent tool to listen to providers - our customers. This is your opportunity to speak directly to your Medicare contractor on various topics.

All calls are toll-free. No registration is needed; however the number of lines is limited.

Appeals Process

May 26, 2005 - 10:00 AM PST/ 1:00 PM EST

National Heritage Insurance Company, (NHIC), Medicare Part B is hosting a one-hour ACT on the Appeals Process. Medicare providers and their staff are encouraged to participate on the conference call.

We will cover the following topics:

  • Redeterminations versus Appeals
  • Reopenings
  • Telephone Redeterminations
  • Written Redeterminations
  • Hearings
  • Administrative Law Judge Hearings
  • Departmental Appeals Boards (DAB) Review
  • Federal Court Review

Important changes regarding the types of denials that can be handled over the telephone will be covered. NHIC will present an overview of the requirements and timeliness for submission of each type of appeal request, and provide important information to help you expedite the efficient handling of your Medicare Part B denials.

NHIC invites you to call in with your questions or comments about Redeterminations and Appeals, toll-free, at 800-857-2283, Pass code:  ACT. There is no registration needed for your participation on this call. However, there are a limited number of lines available. [return to top]

Push for Performance-Based Pay in Health Care Receives a Boost
The Wall Street Journal, May 4, 2005
The Ambulatory Care Quality Alliance (AQA), a coalition including the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), America's Health Insurance Plans (AHIP), and the Agency for Healthcare Research and Quality (AHRQ), announced that it has developed a "starter set" of 26 clinical performance measures for the ambulatory care setting. The goal of the measures is to provide physicians, patients and purchasers with a standard set of quality indicators that may be used for quality improvement, public reporting and pay for performance programs. The quality measures may be incorporated into Medicare's pilot pay for performance programs. The starter set includes prevention measures for cancer screening and vaccinations, measures for chronic conditions including coronary artery disease, heart failure, diabetes, asthma, depression, and prenatal care, and, two efficiency measures that address overuse and misuse.

(American Medical Association's Private Sector Advocacy Update )

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EMR 2015: An Evolving Concept
American Medical News, May 9, 2005
President Bush has stated that he wants all Americans to have a personal health record (PHR), an Internet-based set of tools that allow patients to access and coordinate their lifelong health information. He is expected to release specifics on the plan for implementation sometime this year. However, the definition of what constitutes a PHR is still ambiguous. Two strategies for providing a PHR have emerged. One is based on hospitals providing patients with access to portions of their medical records online. This is usually built into an existing hospital's electronic medical record (EMR) platform. The other approach is usually provided by a vendor and consists of patients entering in their own health information and paying a company to store it on a secure Web site. Critics have concerns about how vendor-sponsored PHRs will be used and maintained. One fear is that patients will enter erroneous information or that patients will let the PHR become outdated.

(American Medical Association's Private Sector Advocacy Update ) [return to top]

MMA Hosts GAO Team Reviewing Flu Vaccine Shortage - You're Invited
The MMA is hosting a meeting with representatives of the U.S. Government Accountability Office who are coming to Maine to conduct interviews about the 2004-2005 flu vaccine shortage.  The meeting will be held at the MMA office in Manchester from 3:30 - 5:00 p.m. on Tuesday, May 10, 2005 and any interested physician is welcome.

The GAO is conducting work in the area of the response to the recent flu vaccine shortage.  Specifically, the GAO has been asked by the House Committee on Government Reform and the Senate Committee on Homeland Security & Governmental Affairs to review the actions taken at federal, state, and local levels to ensure that high-risk individuals had access to flu vaccine during the 2004-2005 shortage; the lessons learned from the strategies implemented at the federal, state, and local levels to ensure that high-risk individuals had access to flu vaccine; and that extent that information on the 2004-2005 flu vaccine supply was made available to health care providers and the public.

The GAO team is seeking responses to the following questions:

1.  Please describe the populations your medical association physicians typically serve, especially pertaining to flu immunization.

2.  Please comment on whether you felt the following actions worked well at the provider level to help ensure access to vaccine by high-risk individuals:

  • ACIP created priority recommendations for vaccinating high-risk individuals
  • CDC's flu vaccine allocation plan
  • CDC referred people looking for flu vaccine to contact their local public health department to find out who had vaccine in their area
  • Use of vaccines for children (VFC) vaccine for non-VFC use (also called VFC transfers)
  • CDC's purchase of Investigational New Drug (IND) vaccine
  • CDC's release of stockpiled doses back to the manufacturer for sale and distribution to providers
  • State or locality invoked an emergency order to vaccinate high-risk individuals
  • Provider surveys to see if you had vaccine or to estimate your need
  • Other actions at federal, state, and local levels

3.  What was your primary source of information on vaccine availability?  In general, were you satisfied with the quality and frequency of information received from federal, state, and local levels?  Why or why not?

4.  Where did providers who did not have flu vaccine refer their patients who were seeking it?

5.  Were the prices providers paid for flu vaccine this year (2004-2005) different from the prices that they had expected to pay (by pre-booking, for example)?

6.  How, if at all, has the shortage affected the provider outlook on immunization programs in general, and will they do anything differently for the 2005-2006 flu season?

7.  What actions taken specifically by providers were most effective to help ensure that high-risk individuals had access to vaccine?  What was the biggest challenge providers faced?

8.  Are there any other shortage-related federal, state, or local actions affecting your department you would like to discuss?

If you would like to attend the meeting, please RSVP to Charyl Smith, Legislative Assistant, at 622-3374 or csmith@mainemed.com.  If you cannot attend, but would like to respond to one or more of the questions mentioned above, please send your responses to Charyl at the email address listed above. [return to top]

Information On Hospital Quality Now Available

Americans will be better able to compare the quality of care in nearly all of the nation’s hospitals using quality information now available from the Centers for Medicare & Medicaid Services (CMS) and the Hospital Quality Alliance (HQA) for the first time ever. 

The new information provides consumers with standardized assessments of the care that nearly 4,200 hospitals across the country provide to all adult patients, based on valid and reliable measures that have been shown to reflect quality of care.   Hospital Compare is available on the Internet at www.hospitalcompare.hhs.gov or www.medicare.gov.   Consumers without web access can call 1-800-MEDICARE (1-800-633-4227) to get the same information on hospital quality. 

“Hospital Compare gives consumers and health professionals quality of care information to help them make more informed decisions about their health care, while providing stronger rewards and support for high-quality, efficient care in the nation’s hospitals,” said CMS Administrator Mark B. McClellan, M.D., Ph.D.  “Not only are we spending more on our health care, but where we choose to get our care matters more than ever before.  Valid, consistent measures of quality care are an important tool to help us make sure we are getting the most for our health care dollars.”

Hospital Compare is the result of a public-private collaboration of government agencies, hospitals, quality experts, purchasers, consumer groups and other health care organizations.  These organizations are working together to develop and implement a national strategy for hospital quality measurement and advancing quality of care.  Many hospitals have been willing to move beyond the minimum set of measures identified by the Medicare Modernization Act payment incentive provision.

“The Hospital Compare will help consumers make more informed decisions about hospital care and will give hospitals the data they need to ensure that they are providing high-quality care,” said Agency for Healthcare Research and Quality Director Carolyn M. Clancy, M.D.  “I would like to commend CMS and the Hospital Quality Alliance for using public reporting to provide information that will benefit consumers, hospitals and the nation.”

In addition, hospitals can call on the expertise of Medicare’s Quality Improvement Organizations (QIOs) for additional assistance in further improving their quality measures. 

“We are providing measures on 17 dimensions of quality now,” said Dr. McClellan. “And we are working hard to make even more comprehensive information on quality available soon. Not every beneficiary needs to pay attention to every measure, but we are developing a much stronger foundation for supporting and rewarding better quality care.  That’s also why we are working with the HQA, the National Quality Forum and other groups to build on these measures.  Together we are committed to achieving our common goal of providing the highest quality care.”

Nearly all of the nation’s eligible hospitals have voluntarily reported up to 17 measures of care for three common, serious health conditions: heart attack, heart failure and pneumonia.  The data was voluntarily submitted by the nation’s hospitals.   Ten of the 17 measures were included in the financial incentive provision established by the Medicare Modernization Act of 2003 and can be viewed on Hospital Compare (the seven additional measures are marked with an asterisk).  The measures include:

Heart attack (acute myocardial infarction)

  1. Aspirin at arrival
  2. Aspirin at discharge
  3. Beta-blocker at arrival
  4. Beta-blocker at discharge
  5. ACE inhibitor for left ventricular systolic dysfunction (LVSD)
  6. Percutaneous transluminal coronary angioplasty (PTCA) within 90 minutes of arrival*
  7. Thrombolytic agent (clot buster) within 30 minutes of arrival*
  8. Smoking cessation counseling*

Heart failure

  1. Left ventricular function (LVF) assessment
  2. ACE inhibitor for left ventricular systolic dysfunction (LVSD)
  3. Smoking cessation counseling*
  4. Discharge instructions*

Pneumonia

  1. Initial antibiotic received within 4 hours of hospital arrival
  2. Pneumococcal vaccination status
  3. Oxygen assessment
  4. Smoking cessation counseling*
  5. Blood culture performed before initial antibiotic received*

Like the other comparative databases available at www.medicare.gov (Nursing Home Compare, Home Health Compare, Dialysis Facility Compare and the Medicare Personal Plan Finder), Hospital Compare will be dynamic, which means that improvements will continue to be made.  In addition to refining the clinical measures hospitals will report, the HQA has endorsed the collection of information about patients’ experiences, and CMS and AHRQ are developing a standardized patient perspective of care survey, known as Hospital-CAHPS (H-CAHPS), which will be added to Hospital Compare in the future.

CMS is continuing to implement the provision of the Medicare Modernization Act of 2003 (MMA) that provides a financial incentive for hospitals to report quality of care data for 10 clinical measures by linking the reporting of these data to the payments they receive for treating Medicare beneficiaries.  Although reporting is voluntary, inpatient acute care hospitals that do not report will get a 0.4 percentage point reduction in their annual Medicare fee schedule update.

"We strongly believe that payment incentives work to get quality reporting and quality improvement, when we use measures that are clinically valid and feasible to produce,” said Dr. McClellan.  “That’s why we will be asking for recommendations on how to better collect and validate the quality measure data that will be used to determine a hospital's payment update factor under the Inpatient Prospective Payment System when we issue the proposed rule in the near future.”

CMS’ Quality Initiative uses a multi-prong approach to drive systems, support and provide incentives to facilities – and the clinicians and professionals working in those settings – in their efforts to achieve superior care through:

  • Ongoing regulation and enforcement conducted by state survey agencies and CMS;
  • New professional and consumer hospital quality information on our websites, www.cms.hhs.gov and www.medicare.gov and at 1-800-MEDICARE;
  • The testing of rewards for superior performance on certain measures of quality;
  • Continual, community-based quality improvement programs through our Quality Improvement Organizations (QIOs); and,
  • Collaboration and partnership to leverage knowledge and resources.
# # #
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Prescription Monitoring Program Update
The Maine Office of Substance Abuse continues the implementation of the Controlled Substances Prescription Monitoring Program passed in the 121st Maine Legislature (P.L. 2003, Chapter 483).  As of late April, the following numbers of prescribers and dispensers have enrolled in the PMP:

  • DDS:  5
  • DMD:  7
  • DO:  50
  • MD:  110
  • NP:  35
  • PA:  27
  • RPh:  43

You can find information about the PMP on the web at:  www.maineosa.org/data/pmp.  OSA has added new reports to the website.  The agency now has data regarding drug types based on patient location for each county along with some numbers showing scripts by age group for schedules and drug types.  The program has collected more than 1 million prescriptions. 

For more information about the program, you can contact:

Chris Baumgartner, PMP Coordinator, Office of Substance Abuse, State House Station 11, Augusta, Maine 04333-0011, 287-3363, chris.baumgartner@maine.gov. [return to top]

Join MMA for an afternoon of Golf at the 2nd Annual Charitable Golf Tournament
The 2nd Annual Maine Medical Association Charitable Golf Tournament will be held on Monday, June 6, 2005 at the Augusta Country Club. A four person scramble will begin at noon, with an awards reception and raffle to take place immediately following. Please contact Chandra Leister (207-622-3374 cleister@mainemed.com) with any questions, or to register a single player or a team.

Net proceeds from the event will benefit the Physician Health Program.

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Space still available for 14th Annual Physician Survival Seminar next Wednesday!
Helen Jameson, JD, Director of Marketplace Advocacy for the AMA's Private Sector Advocacy Group will present the keynote address at the Maine Medical Association's 14th Annual Physician Survival Seminar. The seminar will be held next Wednesday at the Sheraton Hotel in South Portland, and on June 8 in Bangor. The morning session will include updates on Pay for Performance, Dirigo, Improving Outcomes, MaineCare and Medicare. The afternoon sessions include tracks on technology, compliance and practice management.

The CME approved program is open to physicians, office managers, hospital administrators, practice consultants, healthcare attorneys and more.

Please contact Chandra Leister (207-622-3374 cleister@mainemed.com) with any questions and to reserve your space now! [return to top]

Direct-to-consumer drug ads linked to increase in prescriptions
Prescription drug advertisements directed towards consumers appear to increase the likelihood that physicians will prescribe those drugs, according to a study in the current issue of the Journal of  the American Medical Association.  The study, which was conducted by researchers  from the University of California, Davis, used trained actors posing as patients who visited 152 primary care physicians in California and New York complaining of symptoms of depression.  These patients asked doctors for a drug by name, or mentioned that they watched a television program on depression and wondered if medication might help.  The study found that physicians prescribed antidepressants in 76 percent of the visits in which patients made general requests for medicine, and in 56 percent of the visits in which patients made brand-specific requests linked to advertisements.  However, physicians prescribed antipressants in only 31 percent of the visits in which patients made no requests for medication.  The study noted that direct-to-consumer prescription drug advertisting can help provide the opportunity to expand patients' involvement in their own care, but can also lead to over-prescribing of high-priced drugs.  To read a summary of the study:  http://jama.ama-assn.org/cgi/content/short/293/16/1995 [return to top]

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