November 14, 2005

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Dirigo Health Agency Proposes Smaller-than-Expected Savings Offset Payment
In a somewhat contentious meeting on Thursday, the Dirigo Health Agency proposed a savings offset payment of less than two percent of claims paid, less than one-half of the four percent assessment which is allowed by the Dirigo Health legislation. A final decision was not made, however, and another Board meeting has been scheduled for Nov. 22 at 9:00a.m. in Augusta.
The approximately 1.7% assessment would produce $31.3 million in fees from commercial insurance companies and third party administrators in Maine.  The fee, which would begin in January of '06, would be utilized primarily to provide subsidies to enrollees in the DirigoChoice program, but about $7 million would go toward expanding the MaineCare program and another $1 million would support the Maine Quality Forum.

The staff of the Dirigo Agency indicated at the meeting that it needs approximately $40.2 million to run the program at expected levels of enrollment from April 1, 2006 to March 31, 2007.  While some parties involved supported the lower assessment as a compromise, others on both sides continued to raise objections to it.  Consumer interests stated that the assessment was not large enough and argued that it should be higher so that enrollment in DirigoChoice could take place more rapidly.  Insurance and employer interests argued that there should be no savings offset until some real savings are demonstrated.

The somewhat difficult and complex debate currently is starting to turn on the issue of whether the insurance carriers should be negotiating more favorable provider rates, allowing them to absorb the assessment versus adding it to already too high premiums.  But insurers claim that they have not achieved any savings and are unlikely to be able to successful negotiate lower provider fees.  While not commenting on the issue of hospital charges, MMA has stated unequivocally that there has been no savings in the physician office as a result of DirigoChoice.  While MMA supports the program and its attempt to provide an insurance product to the uninsured, it would strain common sense to believe that the fewer than 2000 DirigoChoice enrollees who were previously without insurance have resulted in increased revenue to physicians.  Given the amount of ambulatory charges, many uninsured individuals pay the physician's charges.  Unfortunately, the evidence is also clear that the uninsured wait too long to seek care and many times end up at higher cost settings such as the hospital emergency room.

MMA does, however, agree that the July 1, 2005 MaineCare fee increase ($8.5 million) has had a positive impact.  But unfortunately, any benefit from the increase has been more than wiped out by the additional costs of dealing with the MECMS (claims management) issue and the dramatic increase in medical liability insurance rates, effective Oct. 1.

Final approval of the assessment is likely to occur at the Board meeting on the 22nd.  Written comments can be filed with the Agency until Nov. 18.

Two weeks ago, Insurance Superintendent Alessandro Iuppa ruled that Dirigo Health initiatives have led to $43.7 million in savings, which became the maximum for the assessment.  But the Superintendent's ruling is subject to appeal and both the Maine Association of Health Plans and the Maine Chamber of Commerce are looking at the possibility of appealing to the Superior Court.

MMA staff will continue to follow the issues in this debate very carefully and will report to members and their staffs in this publication and in the pages of Maine Medicine.

Deadline Draws Near to Submit Anthem Claims in Class Action Settlement
Physicians or physician groups that provided services to any individual enrolled in or covered by Anthem between August 4, 1990 and July 15, 2005 must file claim forms with the Settlement Administrator by Nov. 17, 2005.

WellPoint (Anthem) reached agreement with 18 medical societies and organizations on July 11, 2005.  The agreement stipulates that the insurer will pay up to $135 million to its network physicians who submit claims and contribute $5 million to the Physicians' Foundation for Health Systems Innovation, Inc., a non-profit foundation aimed at improving health care for the disadvantaged.

A federal judge will consider the proposed settlement in December.

Claim forms are available online at and must be mailed to:

              WellPoint/Anthem Physicians Settlement Administrator

              P.O. Box 3560

              Portland, Oregon 97208-3560

You may find additional information about the Anthem settlement at [return to top]

Office of Health Policy and Finance Releases Draft State Health Plan
On Nov. 7, the Governor's Office of Health Policy and finance, joined by members of the Advisory Council on Health Systems Development, released the Draft 2006-2007 State Health Plan for public comment.   The draft plan and related materials can be read at

In the weeks ahead, the draft plan will be the subject of public hearings and review by the Legislature's Health and Human Services Committee.  The schedule of public hearings is set forth at the end of this article.

Page 6 of the draft lays out long term goals for access, affordability and quality and establishes explicit benchmarks to assure improved and integrated physical and mental health, specific reductions in substance abuse among high school students, reductions in tobacco use and reductions in unhealthy weight among adolescents and improved diabetes care.  The draft also calls for a sustainable public health infrastructure, a statewide system of comprehensive community coalitions and the establishment of a Rural Health Working Group and a Telehealth Workgroup.

The draft continues support for the Care Model to assure widespread implementation of the model in the state.

Much of the draft deals with the state's strict Certificate of Need Program with priority given to projects that protect public health and safety, contribute to lower costs, increase efficiencies, advance access to services and reflect a collaborative, evidence-based strategy for introducing new services and technologies.  Projects will be given higher priority if they include prevention and population health, promote investment in the MHINT project and cause less than a 0.5% increase in insurance premiums.

The draft also calls for an expansion of DirigoChoice by increasing enrollment of the uninsured by at least 100%.  But it also calls for an independent evaluation of Dirigo Health to identify key successes and areas for improvement.

Public comments will be received on the draft Plan by the Governor's Office of Health Policy and Finance until 5:00p.m., Friday, December 2,  2005.

The public hearing schedule is set forth below:

  • Lewiston, Nov. 21, 11:00a.m. to 2:00p.m., Lewiston/Auburn Campus of the University of Southern Maine, 51 Westminster St.
  • Brewer, Nov. 21, 4:00p.m. to 7:00p.m., Jeff's Catering, East West Industrial Park, 5 Coffin Ave.
  • Portland, Nov. 22, 11:00a.m. to 2:00p.m., University of Southern Maine's Portland Campus, Hannaford Hall in the Abramson Building.

The Maine Medical Association will testify at the hearing in Portland and offer written comments as well.  Watch for copies of the testimony in this publication. [return to top]

Maine Health Data Organization Adopts Draft Rule on Release of Physician Data
The Maine Health Data Organization met last Thursday and considered the written comments filed by MMA and other organizations on proposed changes to MHDO Rule Chapter 120 which, for the first time, will allow the release to the public of practitioner specific data from the claims data base.  The Board voted to support several specific recommendations offered by MMA, including the following:

      1.  Extended the review period from 10 days to 30 days in order to give the practitioner a better opportunity to review the data requested or.reports prepared therefrom.

      2.  Required that Sec. 12 (C) be amended to stipulate that data requests containing identifiable practitioner data elements be reviewed by applicable practitioner related professional organizations and/or the presidents or chairs of Maine based medical specialty societies.

      3.  Provided additional language requiring the practitioner to be tested for accuracy prior to release.

      4.  Extended the effective date of the rule revisions to January 1, 2007.

While not all the MMA recommendations were accepted, these changes will go a long way toward ensuring the accuracy of the data and providing the physician or other practitioner with advance notice of the request.

Because the rule is, by statute, a major substantive rule, it must be reviewed and approved by the Legislature's Health and Human Services Committee in 2006.  The Committee will hold a hearing on the rule which will give the Association another opportunity to provide comments.  While MMA supports the concept of the release of such data  by a publicly accountable agency, there are many safeguards that must be provided in order to assure the accuracy of the data.  In addition, each physician must be given the opportunity to comment on the release prior to it becoming public.  The Association will continue to advocate for a fair process prior to release of any of the claims data from the all-payor claims database.  Only data after Jan. 2003 will be available.

The Maine Quality Forum is expected to be a major user of the data and has proposed its own set of policies to help ensure accuracy and fairness.  Consistent with the purpose of the Forum, the proposed policy provides that the Forum staff will provide individually to practitioners their data when it lies more than two standard deviations from the mean in that specific metric.  This will help to ensure that the physician is not surprised when the data first becomes available to the public.

The availability of physician specific data to the public is an important issue to the public and to the profession.  MMA will continue to report on it in this publication. [return to top]

Maine's Sentinel Event Reporting Law Under Scrutiny
The Maine Quality Forum's Advisory Committee has formed a subcommittee to examine Maine's sentinel event reporting law which was enacted only two years ago.  The committee has met twice and a third meeting is scheduled for Nov. 29.  The subcommittee was asked by MQF Director Dennis Shubert, M.D. to examine the list of reportable events under Maine's law and to compare it to the 27 "serious reportable events" outlined by the National Quality Forum.  The reports are made to state officials in the division of licensing and certification of DHHS but are confidential once received by them and are not available to the public or trial lawyers.

The subcommittee now is focusing on one particular section of Maine's statute which limits reportable events to unanticipated deaths or major permanent loss of function that are "unrelated to the natural course of the patient's underlying condition or proper treatment of that condition,".  The Maine Hospital Association maintains that the standard is the appropriate one, given that the statute was intended to identify and fix system flaws in order to prevent recurrence.  If the event was not due to a process flaw, there is little, if any, benefit in reporting it to the state.

In order to receive more feedback from physicians, the MMA Executive Committee will discuss this issue at its meeting this week (Nov. 16) and provide direction to MMA staff for the Nov. 29 meeting. [return to top]

Reception for Senator Snowe this Saturday evening (Nov. 19) at the Woodlands
A large group of Maine physicians is hosting a fund-raising reception this Saturday for Maine's senior U.S. Senator Olympia J. Snowe.  Senator Snowe is a member of the Senate Finance Committee which has jurisdiction on the Senate side for Medicare and Medicaid.  She has been very active the last few weeks in protecting Medicaid from deep cuts and in supporting physician payment reform in Medicare.

The reception is hosted by Drs. Stuart Gilbert and Lee Thibodeau along with eighteen other physicians.  The cost is $100 per person and anyone may attend by calling 207-774-2006.  Checks are payable to Snowe for Senate.

The reception will be held from 5:30p.m. to 7:30p.m. at the Woodlands, 39 Woods Rd., Falmouth. [return to top]

MaineCare MECMS Update (Claims Management)
The MaineCare MECMS Provider Advisory Committee met last Thursday (Nov. 10) with both Commissioner Nicholas and Deputy Commissioner Mike Hall in attendance.  MMA staff attends each meeting along with about 20 other provider representatives.  The bottom line from this meeting is that the system is still struggling, with suspended claims back up over 350,000, the highest in a month. 

The key weekly metrics sheet showed that for the week ending Nov. 6, 191,066 claims were processed with the following results.

       66.46% were paid through MECMS

       17.53% were denied

       16.01% were suspended

Of the recycled claims, only 30.71% were paid with 17.96% suspended and 51.33% denied.

Deputy Commissioner Hall stated that it was now the goal to reduce the suspended claims inventory to under 250,000 by the end of the year.  A list of 17 "Stabilization Milestones" was also shared with committee members.  The system is not expected to be completed now until July of 2006.

There was further bad news relative to the Part B cross-over payments.  As none have been paid all year, the staff had been experimenting with the processing of the claims on paper, but the test when applied to some claims on UB 92 forms paid the billed amount rather than the coinsurance and deductible amounts.  We expect to hear about more testing early this week and will provide more direction to MMA members and their staffs.  It is estimated that the crossover claims only could be as much as $25 million with much of this amount owed to physician practices.

The Committee meets again on Dec. 8 at 10:00am in Augusta. [return to top]

Next First Friday CME Program on Friday, Dec. 2 at MMA
MMA's fourth First Friday's presentation will feature the three most highly rated talks from the 2005 Physician Survival Programs offered this Spring. If you did not get to one of the PSS programs, here is an excellent year-end opportunity to receive the best of it.  The program is at MMA offices in Manchester from 9:00 a.m. to noon on Dec. 2 and costs only $60 which includes all materials and breakfast.

     The three talks are:

  • Handling the Angry Patient by attorney Michael Duddy of Portland
  • Handling the Angry Physician by PhD psychologist Maggie Palmer
  • Employment Law Update by Portland attorney John Gleason

You may reserve a space by calling 622-3374 and asking for Gail. 


  [return to top]

Medicare Payment Reduction Fix Still Being Worked On in Washington
MMA President Jacob Gerritsen, M.D., an internist from Camden, will travel to Washington D.C. on Thursday, Nov. 17 to attend a hearing of the Health Subcommittee of the House Energy and Commerce Committee upon which Maine Representative Tom Allen sits.  The hearing will deal with the subject of Pay for Performance in Medicare  but it will also give physicians an opportunity to remind House members that if they adjourn the session at the end of the year without fixing the Medicare payment problem, fees will be decreased by 4.4% January 1. 

The Senate voted earlier this month (52-47) to approve a fiscal year 2006 budget bill which contains $10 billion in spending reductions to Medicare and Medicaid over five years.  The changes, first approved by the Seate Finance Committee, cancel the scheduled fee reduction and raise payments next year by 1%.

The AMA, with support from the major Medical Specialty Societies, continues to push for a two-year fix that would include an update at least equal to the increases in the Medicare Economic Index.  The Senate also passed language imposing a Pay for Performance program that is not as favorable to physcian interests as the bill sponsored by Nancy Johnson in the House.

At the end of this week, the Congress will recess until early December, which will give physicians an opportunity to meet with their federal representatives in their home state offices.  Access to care for seniors is at risk as physicians have continued too bear the brunt of fee reductions in the past, while other facilities have received regular updates. [return to top]

Helping Seniors with the Medicare Drug Benefit; Sign-up Begins THIS WEEK
Enrollment in the Medicare drug plans begin Tuesday, Nov. 15.  If you treat seniors, your patients may soon turn to you and your staff with questions about the new drug benefit.  MMA hosted an educational program for office staff last week, but there are many other sources of information available.  Resources are available to help your patients make decisions about the programs at and   Physicians may wish to visit for additional information and a beneficiary toolkit about the Medicare drug benefit.

Seniors in Maine have over 40 plans from several different carriers to chose from, but it is expected that many seniors will not apply, both because of the additional premium and the complexity and controversy surrounding the plans.  They may enroll without penalty until May 15, 2006, but must enroll by the end of this year for coverage beginning Jan. 1, 2006.

Seniors and disabled beneficiaries with limited incomes will be able to get the new benefit with little or no out-of-pocket costs.  Individuals who have incomes under $14,355 (under$19,245 per couple) may apply for extra help to pay for annual deductibles, premiums and copayments.  The average monthly premium for coverage equivalent to Medicare's standard coverage is about $32per month.

The Maine Primary Care Association is also presenting a series of 90 minute briefing sessions for office staff.  There are several scheduled around the state with the latest being in Portland on Dec. 16.  To receive more informaiton on these programs or to register,  e-mail Andrea Watkins at:  These programs are done in partnership with the Office of MaineCare Services and are offered free of charge. [return to top]

Washington State Ballot Initiative on Liability Reform Falls Short
A ballot measure that would have widened access to care for patients throughout the state of Washington came up short in last week's general election.

Nearly 46 percent of voters backed Initiative 330, a medical liability reform measure that would have set a $350,000 cap on noneconomic damages awarded against all health care professionals, entities and institutions.  That limit could have increased to $1,050,000 depending on the number of health care institutions involved and their type of liability.  An opposing ballot initiative, Initiative 336, sponsored by trial.l lawyer interests, was defeated more resoundingly.  Almost 59 percent of voters rejected that measure, which Washington State Medical Association officials said threatened to create a more state-run bureaucracy while benefiting personal injury lawyers more than patients. [return to top]

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