October 10, 2005

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More on Aetna/Cigna Specialty Networks, Cigna Letters are on the Way
Letters to Maine physicians announcing the results of the Cigna selection of Maine physicians for its specialty network were mailed from New Jersey on Thursday (Oct. 6)and should be in the hands of Maine practices early this week. Only about 25% of eligible physicians have been selected based upon criteria that included evaluation of the physician utilizing "Episode of Treatment Group" (ETG), which was also used in the Aetna selection process.
On Wednesday evening, Oct. 19, MMA's Payor Liaison Committee will again meet to discuss the establishment of these specialty networks and the validity of the measurements. One concern expressed at the previous meeting in September is that the ETG includes the entire episode of care, regardless of whether the patient has received medical treatment as an outpatient, inpatient, or both. Therefore, it is difficult for a specialist to be on the preferred list if he or she practices at a high cost hospital.

An Episode of Treament Group is an illness classification system that identifies discretely occurring episodes of care. ETGs identify and classify entire episodes of care, regardless of whether the patient has received medical treatment as an outpatient, inpatient, or both. Like the Diagnosis Related Groups (DRGs) of the past, ETGs were designed as a tool to measure the provision and financing of health care services. For more detailed information on ETGs, log on to www.symmetry-health.com.

The meeting on the 19th begins with dinner at 6:00p.m. Any MMA member is welcome to attend but give us a call at 622-3374 so we can be sure to have enough food and materials.

The Aetna and Cigna announcements have generated much interest among specialists in Maine. While the preferred networks will only be made available on an optional basis to employers who are self-insured (only one employer so far has elected to include the option in the case of Cigna), physicians are still very concerned about the methodology and the impact on their reputation if they are not identified as a "preferred" provider.

Medicare Payment Cut Effective 1/1/06 Not Yet Fixed
The AMA and national medical specialty societies continue to work to avert the planned 4.3% reduction in physician payments from Medicare due to occur on Jan. 1, 2006. A plan has surfaced following a meeting of a subcommittee of the Senate Finance Committee which would freeze payments at their existing level but the AMA has correctly noted that a freeze is really still a cut, given the increasing costs of running a practice. Senator Olympia Snowe is a prominent member of the Senate Finance Committee and will play an important role in determining how to deal with the SGR (sustainable growth rate) formula. Maine physicians should communicate with the Senator and her staff and indicate how important it is to fix this payment problem. Senator Snowe's number in the D.C. office is 202-224-5344. Call or send a fax to the fax number 202-224-1946. Senator Susan Collins and Representatives Mike Michaud and Tom Allen have co-sponsored legislation favorable to physicians that would provide a modest increase in payments, effective Jan. 1.Any permanent fix is likely to include a pay for performance provision. Last week's House and Ways and Means Health Subcommittee hearing on H.R. 3617, "Medicare Value-Based Purchasing for Physicians' Services Act of 2005", provided a glimpse of what physicians can expect in the move to pay for performance.At the hearing, CMS Administrator Mark McClellan, M.D., reported that CMS intends to roll out a voluntary quality reporting system for physicians next year. Without legislation it is possible that physicians will not receive additional compensation for participating in the voluntary reporting program, similar to the first year of the current hospital quality reporting program. His comments reaffirmed the agency's commitment to establish some form of pay for P4P or "Value Based Purchasing" program, with or without legislation.

McClellan reported significant progress toward reaching consensus on primary care quality measures and developing quality measures for the majority of physician specialties. McClellan noted that 66 measures for 29 specialties, representing 80 percent of Medicare physician spending, have been developed. He also noted that CMS should have the infrastructure in place next year to allow reporting of these measures on existing physician claims.

At the hearing, AMA Trustee John Armstrong, MD, focused on the need to repeal the SGR and derail predicted payment cuts of over 26% between now and 2009. On P4P, the AMA recommended the legislation be amended to include the ability of physicians to have prior review, appeal and comment on any individual physician quality data that will be publicly reported. Additionally, AMA calls for pilot-testing of any value based purchasing program prior to full implementaiton, and that efficiency measures must be evidence-based, valid, and developed by the medical specialty societies in a transparent process similar to the mandate for clinical measures. [return to top]

Medicare Shuts the Door on HIPAA Claims Contingency Plan
As also noted in last week's Maine Medicine Weekly Update, effective Oct. 1, 2005 any electronic claim submitted to Medicare in a non-HIPAA compliant format will be rejected on the front end. A message will be sent indicating that the claim was rejected because a non-HIPAA compliant format was used.

Physicians should ensure that their electronic billing systems are currently submitting claims to National Heritage Insurance Company (NHIC), the Medicare Part B carrier for Maine, in a HIPAA-compliant format. If you have questions, contact the NHIC's EDI department at 781-749-7745. [return to top]

Maine Coalition to Fight Prostate Cancer to Hold First Gathering Saturday, Oct.. 22
The Maine Coalition to Fight Prostate Cancer will hold its first "Gathering" of Prostate Cancer Support Groups in Maine on Oct. 22, 2005 at the Kennebec Valley Community College in Fairfield. Support group leaders, men, partners and friends whose lives have been touched by prostate cancer are welcome to attend by calling 207-623-5375 or via e-mail to nleavittassoc@netzero.net. Please RSVP by Oct. 15.

The program starts with sign-in at 9:15AM and concludes at 2:30PM. There is no cost to attend. Speakers include Fred Gersh and Kathy Meade from Virginia.

Urologists, oncologists and primary care physicians with patients who have survived prostate cancer may wish to make this program known to those who might benefit. [return to top]

MMA, NHMS and Affiliated Healthcare Systems Team up to Present Disinfection, Sterilization and Decontamination Program
Watch for your Sept./Oct. Maine Medicine which contains an insert on an upcoming program designed for office personnel entitled, "Best Practices for Decontamination, Disinfection and Sterilization of Instruments in the Physician Office." The programs in Maine will be held Nov. 1 in Bangor (Spectacular Event Center) and Nov. 2 in So. Portland (Sheraton). An additional program will be held on Nov. 3 in Bedford, N.H.

The presenter is Nancy Chobin, RN, AAS, CSPDT, CSPDS, CSIT CSPDM, who has presented this program in Maine previously to wide acclaim. The program is from 8:30am (registration begins at 8:00am) and concludes at 1:00pm. In addition to information on decontamination, disinfection and sterilization, regulatory and safety issues associated with chemicals and sterilation methods will also be identified and reviewed.

CEU's are pending for nurses and medical assistants. The cost is $65 for members and $75 for non-members (existing customers of Affiliated Healthcare Systems also receive member price).

For more information on the program, call 1-800-648-2727. [return to top]

Next "First Friday" Program on Medicare, Part D
The next program in MMA's "First Friday" CME series is on Medicare Part D and is intended to prepare the physician practice to assist patients who are seniors and need information on the Part D drug benefit. The primary presenter is Anne Smith of Legal Services for the Elderly. Other speakers will be announced shortly. The program will be on Friday morning, Nov. 4, 2005 from 9:00am to noon at the offices of MMA in Manchester, Maine.

In addition to Medicare, Part D, other provisions affecting physicians that were included in the Medicare Modernization Act will be discussed. Registration materials are included in the Sept./Oct issue of Maine Medicine but you may call Chandra Leister at 622-3374 or via e-mail to cleister@mainemed.com to reserve your seat. The cost is $60 which includes breakfast and extensive written materials. [return to top]

Materials from "Preventing Prescription Drug Diversion" and Program Itself Available
MMA's second "First Friday" program, on the subject of preventing prescription drug diversion, was held this past Friday at the MMA office in Manchester. The program was well received with nearly 40 physicians and office staff in attendance. A limited number of packets of materials prepared for the program are available for purchase at a cost of $15.00. The packet contains information on Maine's new Prescription Monitoring Program, material from the Maine DEA, the licensing board rules and a suggested protocal for your office. Contact Chandra Leister at 622-3374 or via e-mail to cleister@mainemed.com for your packet.

The program itself, which discusses the delicate balancing of adequately treating pain without inadvertantly fueling diversion and addiction, is being offered for grand rounds, medical staff meetings or health center presentations. The program can be customized for presentations ranging from 90 minutes to 3 hours. CME is available for the program. An honorarium of $300, payable to MMA, is charged. If your health center or medical staff is interested, contact Gordon Smith, Esq. at MMA at 622-3374 or via e-mail to gsmith@mainemed.com. [return to top]

Legislative Update: Submission of Health Care Claims
L.D. 416, "An Act to Amend the Laws regarding the Submission of Health Insurance Carriers" went into effect on Oct. 1. The law essentially mandates consistent billing practices. Specifically, all claims for professional services must be submitted on the standardized federal form (HCFA 1500) and practices with more than 10 providers must submit claims in electronic data format.

For more information on this law and its impact on your practice, contact Andrew MacLean, Esq. at MMA at 622-3374 or via e-mail to amaclean@mainemed.com. [return to top]

MaineCare MECMS Provider Advisory Committee Meets Thursday (10/13)
The MaineCare Provider Advisory Committee established to advise the DHHS on the MECMS claims management problems will meet again on this coming Thursday, Oct. 13 in Augusta. These meetings are open to the public. The meeting will be held at 10:00am at the DHHS offices on Civic Center Drive in Augusta.

The two-hour meeting will include an update on how the system is functioning currently. We also expect to hear information on the planned payment of cross-over claims. At the most recent meeting of the Committee, Deputy Commissioner Mike Hall indicated that it was hoped the anticipated payment date of February, 2006 could be improved upon.

The MMA is still interested in receiving information from practices as to ANY additional costs incurred because of the MECMS problem. DHHS staff is preparing a report for the Commissioner, which is likely to used at the Legislature, on the magnitude of these costs. MMA has advocated for these costs to be reimbursed by the state. A big thank you to those practices which have sent data, but we could use more. Send it to Gordon Smith at gsmith@mainemed.com.

MMA will report on the Thursday meeting in MMWU next Monday. [return to top]

Blue Ribbon Commission on the Future of MaineCare to Meet on Tuesday (Oct. 11)
After a significant delay it its appointment, the new Blue Ribbon Commision on the Future of MaineCare will hold its first meeting on this coming Tuesday morning, beginning at 9:30am at the State House in Augusta. MMA staff will attend the meeting and report to members through Maine Medicine and Maine Medicine Weekly Update. The Commissioner has scheduled four meetings this Fall. [return to top]

Dan Hanley Memorial Trust Recognizes Sandra and Burgess Record
At a luncheon held at Bowdoin College last Friday, the Dan Hanley Memorial Trust presented its Annual Leadership Award to Sandra Record,RN and Burgess Record,MD. The Records' outstanding leadership over the past three decades has made a demonstrable difference in the health of the citizens of Franklin County and the State of Maine. Working as a team, the couple has employed a combination of good patient care and population-based public health approaches to develop unique model of success in the prevention and treament of heart disease.

The Records' innovative and collaborative approach has inspired countless health professionals across Maine to commit themselves to initiatives aimed at decreasing the terrible toll that hypertension, tobacco use, obesity, diabetes and inactivity take on the hearts of Maine people. As a nurse and physician team, the Records have taken advantage of the best that both of these professions can offer.

Thanks in large part to their intense commitment, tenacity, hard work and leadership, Franklin County has established itself as Maine's premier center of excellence for disease prevention and health promotion. Sandy and Burgess Record's work exemplifies Dr. Dan Hanley's core values and have made a real difference in saving lives and improving the overall health of their community.

The Maine Medical Association congratulate Sandra and Burgess Record for this well-deserved recognition. [return to top]

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