July 18, 2005

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Governor Announces Full-Scale Review and Redesign of Office of MaineCare Services
On last Wednesday, July 13, Governor Baldacci held a press briefing to announce that he has ordered a full-scale review and redesign of the Office of MaineCare Services [formerly known as the Bureau of Medical Services (BMS)]. The Governor acknowledged that in looking at the MECMS situation, the Department had uncovered deeper structural weaknesses at MaineCare, many of which had existed for decades.
At a Provider Advisory Committee meeting held on Thursday, Commissioner Jack Nicholas and Deputy Commission John Michael Hall noted that even if the MECMS problems are fixed, the cultural problems would remain without fundamental and system-wide change. 

"Through conversations with providers, MaineCare staff, and other stakeholders, we have learned that the circumstances that gave rise to the premature deployment of MECMS are symptomatic of profound, longstanding issues at BMS that, if left unaddressed, will inevitably foster similar crises in the future," Mike Hall said in a statement released to the media.

Deloitte Consulting has been engaged by the state to work on the Transformation Project.  Each Deloitte staff member will have a particular focus and expertise:  claims management, provider relations, business processes, organizational leadership and development and customer service.  Beginning this week, they will evaluate the current organization, map decision processes, determine where staff are deployed and assess effectiveness and capacity to meet the myriad demands that are made on the Bureau.

The Department will begin receiving input from providers in early September, initiating a discussion of the agency's core mission and priorities as part of designing the new structure and work methods.  Providers will be asked what works well, but also what aspects of their interactions with MaineCare are inefficient or burdensome, which requirements distract them from focusing on patient care.  "We cannot eliminate every piece of documentation or paperwork, but we can work on subtracting those that have little real utility and then streamlining others so that transactions with MaineCare more closely resemble the routine transactions your members have with other insurance carriers," Mike Hall stated.

The Provider Advisory Committee will meet again on July 28 at the DHHS office in Augusta.  While the Provider Advisory Committee was organized primarily to provide input into the MECMS situation, it is likely that the Transformation Project will also continue to be discussed, particularly until a new Advisory Committee is appointed to work directly on the Project.

The Governor noted in his press conference that the Bureau had lost the confidence of providers, recipients and the public.  The objective of the Project is to restore that confidence.

The MaineCare program provides coverage for more than 300,000 Maine people.  It represents over 20% of the state's general fund.

The press statement issued by Deputy Commissioner Hall follows in its entirety:

Dear Provider:

On Wednesday afternoon, Governor Baldacci held a press briefing to announce that he has ordered a full-scale review and redesign of the Office of MaineCare Services (formerly known as the “Bureau of Medical Services / BMS”).During the press conference, the Governor laid out the plan to transform the new Office of MaineCare Services, insuring that it operates as a high-performing organization, equipped to meet the needs of recipients and medical providers.

The plan, and the overall effort, is designed around a framework of Medicaid Excellence, using state-of-the-art performance benchmarks in the areas of management and administration, technology, and performance outcomes (including quality of care, financial stewardship, and customer service). Make no mistake about our ambitions:we intend to design an organization that is a model for the rest of the nation.

Over the last several months, much of our collective attention has been focused on the formidable problems with the new claims processing system, MECMS.I want you and your members to know that our attention and determination to resolve those problems will not wane as we undertake this new initiative.In fact, in the past two weeks, I have moved aggressively to strengthen project management, identify system defects and move system upgrades and repairs into production.We are committed to expeditious implementation of a robust, fully-functional MECMS system and financial/accounting/audit processes.

But even as we continue that effort, the MECMS situation has uncovered deeper structural weaknesses at MaineCare, many of which have existed for decades.Through conversations with providers, MaineCare staff, and other stakeholders, we have learned that the circumstances that gave rise to the premature deployment of MECMS are symptomatic of profound, longstanding issues at BMS that, if left unaddressed, will inevitably foster similar crises in the future.This is the moment to recognize that MaineCare is the backbone for health services in our state and that making it fundamentally stronger is imperative.

Governor Baldacci has approved a three-phase approach, including an “assessment” phase, a “strategization” phase, and an “implementation and management” phase. The transformation project will address a number of issues at OMS, including its overall business model, performance measures, business processes, organizational design, contract management, and financial management.

I have asked the Deloitte Consulting firm to work with us on this project.A team of 4-5 other experts who have considerable experience working with state Medicaid programs will join Matt Kouri and Drew Beckley from Deloitte.Each Deloitte staff member will have a particular focus and expertise:claims management, provider relations, business processes, organizational leadership and development, customer service.Starting next week, they will roll up their sleeves and begin working with us to evaluate the current organization, map our decision processes, determine where staff are deployed and assess our effectiveness and capacity to meet the myriad demands that come our way.

In early September, we’ll initiate a discussion of the agency’s core mission and priorities as part of designing the new structure and work methods.We will need help and input from you and your members.We’ll be asking what works well, but also what aspects of their interactions with MaineCare are inefficient or burdensome, which requirements distract them from focusing on patient care.We cannot eliminate every piece of documentation or paperwork, but we can work on subtracting those that have little real utility and then streamlining others so that transactions with MaineCare more closely resemble the routine transactions your members have with other insurance carriers.

Throughout my career, I have preached and practiced open, frank, credible communications with providers.As we move forward, I will work with Commissioner Nicholas to embed a process of provider engagement by establishing an Advisory Committee that can serve as a sounding board to gauge whether we’re on the right track. In the meantime, the Commissioner and I will meet with the Governor’s Provider Advisory Group on MECMS to describe the OMS transformation project and answer questions about the plan.

BMS has been operating in an environment of inadequate resources, unrelenting stress and perpetual crisis for as long as most of us can remember.It has taken a damaging toll on the staff and, at one time or another, our providers have probably been on the receiving end of that stress. We need to fix that and we need to do it soon.It will require significant changes in how we do this work and who does what, but MaineCare will be a healthier, more sane, more capable organization when we get done.

I think the Governor said it best at the press conference:our objective is to regain the confidence of providers, MaineCare recipients, and the people of Maine.I look forward to working with you in the coming months to achieve that objective.


John Michael Hall
Deputy Commissioner
Acting Director, OMS

Governor's Drug Importation Task Force Considers Options
For the last several years, the Executive and Legislative branches of Maine government have been interested in exploring the importation of prescription drugs from Canada as a part of the effort to improve access to affordable medications for Maine citizens.  Drug importation has been a hot topic in Washington, D.C. and around the country as well, but Maine's position as a border state and bus trips to Canada organized by senior citizen groups have put this issue high on the agenda of Maine's policymakers. 

During the recently completed session, the legislature enacted L.D. 1178, An Act Regarding Access to Prescription Drugs and Reimportation.  The MMA is a member of a task force established in this legislation to consider how the State might establish a more formal way of assisting Maine citizens in importing drugs from Canada.  You can view the new law and the duties of the task force on the web at:  http://janus.state.me.us/legis/LawMakerWeb/externalsiteframe.asp?ID=280016134&LD=1178&Type=1&SessionID=6.

The drug importation study group is considering several options, but must consider two significant issues in deciding on a course of action:

1.  Importing drugs from abroad is a violation of federal law.  However, the federal government long has exercised prosecutorial discretion to not enforce the law with respect to "personal use."  It is this "personal use" exception that has permitted the bus trips to continue.  Also, Congress is considering legislation to permit some importation under a bill sponsored by Senator Snowe and Senator Byron Dorgan (D-ND).

2.  FDA approval is the "standard of care" for drugs in our country and even if federal law changed to permit importation, physicians would have to be assured that they are not going to face liability for being involved in the patient's use of potentially unsafe drugs.

Megan Renfrew, a Policy Intern in the Governor's Office of Health Policy & Finance, is staffing the working group and she has completed substantial background research on similar activity in other states and municipalities.  She has proposed 6 different options ranging from a simple web link on the state web site, www.maine.gov, to a state-sponsored drug wholesale operation.  Megan is a student at Columbia Law School and is the daughter of MMA member Roger Renfrew, M.D. of Skowhegan.

The working group must submit a report and recommendations to the Health & Human Services Committee by January 15, 2006. [return to top]

WellPoint/Anthem Settles Class-Action Lawsuit with Physicians for Nearly $200 Million

Health plan company WellPoint (which owns Anthem Blue Cross and Blue Shield of Maine) will pay $198 million to settle allegations brought in a class-action lawsuit by 18 state medical associations on behalf of 700,000 physicians. The associations accused the company of underpaying for physician services and allowing hospitals to bill WellPoint members for services the company should have paid. Under the settlement agreement, WellPoint will pay $135 million to physicians, contribute $5 million to set up a foundation to promote quality health care and improve health care delivery to the uninsured, and pay up to $58 million in legal fees. WellPoint serves 28.2 million members and operates Blue Cross and Blue Shield HMOs and other health plans in 13 states. For more information, visit Wellpoint.  As we have in the Aetna and Cigna settlements, MMA will continue to provide members with information on the settlements and the opportunities to participate.

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Aetna to Roll Out Specialty Network in Maine, January, 2006
MMA has been advised by Aetna representatives of the Health Plan's intention to utilize in Maine a selective network of specialty physicians in a dozen specialties come January.  This Aexcel Network has been piloted in a few states and is being rolled out on a broader basis in '06.  Specialists will be selected based upon an announced criteria and any non-designated Aexcel physician will not be eligible to participate until after the end of the second year.  The criteria for selection will involve what company officials state is a "balance of measures of clinical performance and efficiency."

MMA understands that another major insurer will be making a similar announcement soon.  Certainly the use of a specialty network will raise important issues in a largely rural state where the demand for physician services always outstrips supply.  In the past, Maine physicians have generally had the opportunity to participate in any of the health plans being offered in the state, subject only to routine credentialing standards.

What follows is a statement from Aetna regarding the new network.  Physicians will be notified in the coming weeks by Aetna regarding the program.

Aetna Introduces AexcelSM in Maine

As health care costs continue to climb, Aetna’s customers and their employees face difficult benefit decisions. Aetna developed Aexcel at the request of large employers who are facing rising health care expenses. Aexcel is intended to help mitigate increases in medical cost trends while maintaining access to quality care.

Aexcel-designated specialists have met certain measures of clinical performance and cost-effectiveness. They are part of Aetna’s network option, the Performance Network, which is comprised of Aexcel-designated specialists, Aetna participating primary care providers, hospitals and physicians in non-Aexcel specialties.

Launched in 2004, Aexcel is currently available in nine locations across the country. Beginning January 1, 2006, Aexcel will be available in several new locations, including Maine. It is currently available to members with the following network-based Aetna products when offered in connection with a self-funded benefits plan: Aetna HealthFund® and all PPO, EPO and

POS products. Aetna also has approval to offer Aexcel with fully insured plans in eight states: FL, TX, CA, CT, D.C., GA, MD, VA and NY.

As in the past, Aetna continues the dialogue with individual network physicians as well as national medical specialty societies, state medical societies and medical groups and associations in locations where Aexcel is introduced. Specialists designated for Aexcel will be sent more information shortly including details about the evaluation process.

Aetna chose to address specialty care in developing Aexcel because it drives most of the advances in procedures, pharmaceuticals, and diagnostic imaging and the increases in costs that accompany these advances

Aetna’s Performance Network encourages members to seek care from Aexcel-designated specialists, resulting in potential increase in Aetna members’ volume in those practices. An Aexcel-designated specialist does not need to have a PCP referral in order to render care to Aexcel members, regardless of the referral requirements of the member’s medical plan.

Aexcel designation currently applies to 12 specialty categories:

  • Cardiology
  • obstetrics and gynecology
  • cardiothoracic surgery
  • orthopedics
  • gastroenterology
  • otolaryngology
  • general surgery
  • plastic surgery
  • neurology
  • urology
  • neurosurgery
  • vascular surgery.

Components of the Aexcel evaluation process include:

  • Case Volume. Those practices/specialist groups managing a minimum number of cases of Aetna members in the 2-year evaluation period are considered for Aexcel designation.
  • Clinical Performance. Physicians who meet the case volume threshold are then evaluated against established measures of clinical performance. Examples include:
    • A specialist’s rate of his/her patients’ hospital readmissions over a 30-day period compared with his/her peers in the same specialty or specialty group.
    • The rate of unexpected adverse health events experienced by a specialist’s hospitalized patients.
    • For cardiologists, the rate of use of cholesterol lowering medication in patients with coronary artery disease; ACE Inhibitor (ACEI) or Angiotensin Receptor Blocker (ARB) in members with Chronic Heart Failure (CHF); Beta Blocker in members identified with Ischemic Heart Disease (IHD) who have had a heart attack.
    • For obstetricians/gynecologists, the rate of cervical cancer screening (i.e., Pap smear or similar test), the rate of breast cancer screening (mammography), and the rate of HIV testing in pregnant women.
  • Cost-Efficiency. Aetna measures cost-efficiency of care by applying Episode Treatment Groups (ETG) analysis. This sophisticated, risk-adjusted analytic tool evaluates the cost of all of the care consumed in treating the entire episode of an illness.
  • Network Adequacy. Aetna is aware the health care system—including the organization of specialty practices, the population base and member density—differs by market. Local markets will make adjustments to make available appropriate access to specialty care.

Aetna is committed to continuing its dialogue with the Maine Medical Association, and medical groups and associations as Aexcel is introduced.We welcome and value the medical community’s input on this and other issues. [return to top]

Top Four Federal Physicians Come to Maine to Tout Medicare Part D Prescription Drug Benefit
The top four physicians in the federal government came to Scarborough, Maine last Wednesday to promote the new Medicare prescription drug benefit which begins on Jan. 1, 2006.  Mark McClellan, M.D., CMS Administrator, Surgeon General Richard Carmona,M.D.,  CDC Director Julie Gerberding, M.D. and Elias Zerhouni, M.D.,  Director of the National Institutes of Health spoke to a group assembled at the Southern Maine Agency on Aging.  MMA staff participated in the event.

The "Four docs" bus tour, as it is dubbed by CMS, aims to raise awareness of the voluntary drug benefit which Medicare recipients can begin to enroll in Nov. 15.

Because the various carriers of the benefit in Maine haven't been announced, the program was short on details but certainly the considerable fire-power from Washington drew attention.  New York Times health reporter Robert Pear was among those attending, leading to a a feature piece on the front page of the yesterday's Sunday New York Times.

The drug benefit will be available to about 240,000 Medicare enrollees in Maine.

At a meeting with stakeholder groups prior to the public session, MMA EVP Gordon Smith asked Dr. McClellan for his assistance in urging Congress to include benzodiazepines on the Medicare formulary.  As this class of medication, used by many seniors, was excluded from the coverage originally, it will take an act of Congress to provide coverage.  McClellan noted in response to the question that it is hoped that state Medicaid drug programs will continue to offer benzodiazepines and that federal matching funds will continue to be paid to the states for them. [return to top]

Making the Connection: Human Health in a Changing Environment
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Children's Insurance Program to Experience Shortfalls

The State Children's Health Insurance Program (SCHIP) could experience money shortfalls in several states over the next two years unless Congress acts, USA Today reported. Federal SCHIP funds will total $4.1 billion in fiscal year 2006, but projected demand for funds will be about $5 billion to $6 billion, according to a report by the nonpartisan Congressional Research Service. From six to 14 states will reach their limit on federal money for the program during the 2006 budget year. By the next year, up to 20 states could use up their funding. Once states spend their federal share, they either have to use more of their own money to provide coverage, or reduce expenses by cutting services. SCHIP generally covers children in families whose income is too much to quality for Medicaid but who cannot afford private health insurance. Read the full text of the article. [return to top]

HIPAA Database Will Store Violation Complaints

The Centers for Medicare and Medicaid Services is using a new database to track complaints of violations of HIPAA's transactions, security and unique identifier rules. The database, which is housed in AT&T's Ashburn, Va.-based facility, will store information from Office of E-Health Standards and Services regional investigations of possible HIPAA violations. It includes a search capability, and workflow and reporting tools. For more information:

http://www.healthdatamanagement.com/html/news/NewsStory.cfm?DID=12853 [return to top]

Dirigo Health Board of Directors: Meeting Update
The Dirigo Health Board of Directors met on July 11.  Board members received updates on the status of the 05 enrollment cap for sole proprietors/individuals, the working group established by the Legislature to make recommendations to the Dirigo Board on the savings offset payment (SOP) and other related issues and a sales update.

As of the end of June, 7,311 members had enrolled which includes 4400 sole proprietors and individuals.  This category has already met the yearly cap imposed by Anthem.  The Governor's Office of Health Policy and Finance is negotiating with Anthem to expand eligibility beyond the cap in 06.  Between 15,000 and 28,000 would be the range of possibilities for the negotiation.

The SOP work group has met several times and is scheduled to meet again on July 19, July 21 and July 26.  Dirigo staff has suggested to the group that its work should be completed by August 28 or 29 so that the Board can consider its recommendations at its 8/29 meeting.  The Bureau of Insurance hearing on the issue is Oct. 27 but the Board must make its filing with the Bureau by Sept. 17.  Trish Riley encouraged the Board to have a contingency plan in place if the savings demonstrated is inadequate to support the existing program.

Ms. Riley also commented at the meeting that Maine has the lowest percentage of employer-sponsored health insurance in New England, but that New England has a high rate of coverage compared to the nation as a whole.

July enrollment figures for the partial month were around 300, not including any individual/sole proprietors.  Sixty to seventy small businesses are enrolling each month.

The Dirigo Board will meet next on August 1. [return to top]

Upcoming MMA Events: Annual Session; Conference on Physician Health; Technology Conference; First Friday's CME
Beginning in early September, MMA is hosting a number of events and conferences that members and their staffs may take advantage of.  On Sept. 8, the Committee on Physician Health and the Lawyer's Assistance Program presents "Protecting the Public/Restoring the Professional", at the Harborside Hotel and Marina in Bar Harbor.  At the same location, the MMA's 152nd Annual Session, entitled this year, "Emerging Threats in Infectious Disease" will be held from Sept. 9-11.  On the first Friday morning of each month, beginning in Sept., a CME program will be held at MMA.  The first topic is on  legal issues involving caring for children (Sept. 2).  The Sept. 2 program is co-sponsored by the Maine Chapter of the American Academy of Pediatircs.

Finally on Wednesday, Sept. 28th, MMA will sponsor with the Maine Chapter of the MGMA a Technology Conference at the Augusta Civic Center in Augusta. 

Call MMA now at 622-3374 or 1-800-772-0815 for registration information on any of the above programs.  Watch for inserts in the July-August issue of Maine Medicine. [return to top]

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