April 17, 2006

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CIO Magazine Details Difficult Transition of MaineCare MECMS Project
CIO Magazine has recently published an article detailing the errors that led to the premature implementation of the MaineCare MECMS system. Author Allan Holmes has noted that this was no way to transition to a new claims processing and information system for a $2 billion health plan. If you are wondering what went wrong, this article is a must-read.
It has now been approximately 15 months since the MECMS project went live.  Many MMA members and staff have asked MMA representatives what went wrong - why did it go this badly and who is to blame?   A lot of the answers are found this week in an article just published in CIO Magazine.  This magazine is essentially a trade publication for technology officers and is widely read throughout the world.

Allan Holmes, author of the article, interviewed a number of persons, including MMA President-elect Kevin Flanigan and MMA EVP Gordon Smith and has pieced together what MMA considers to be the most definitive article yet detailing what went wrong.  It is a lengthy article, but is recommended reading for anyone who wonders about the decision-making at state government on a project of this magnitude.  While certainly concluding that this was no way to transition to a new payment and information management system, the article is pretty-much neutral from a political standpoint, which is one reason it is such a valuable contribution.

You may access the article at http://www.cio.com/archive/041506/maine.html?action=print

MaineCare MECMS Update; Recovery of Interim Payments
The Governor's Provider Advisory Committee on MECMS met on Thursday and heard updates on timely filing, the OMS Reorganization, interim payment recovery (and cash flow) and other financial issues.

Over $216 million of the $225 million goal for recovery of interim payments has been collected or is subject to agreements to collect.  These repayments, along with the additional $50 million moved into 2006 as part of the supplemental budget and $10 million  additionally appropriated ensures that there should be no problem with the state meeting its obligations to MaineCare providers through the end of the state's fiscal year.

Weekly metrics for the week ending April 9, 2006 showed 75.08% of fresh claims being paid, with 13.44% being denied and 11.48% falling into suspension.  Suspended claims are down to 185,912, the lowest number in a few weeks.  Tracking these metrics over the past five weeks, the % of fresh claims paid ranged from a low of 71.47% to a high of 75.22%, showing some stability over the past few weeks.

Several key positions have been filled in the OMS Reorganization, including:

  • Kim Negron as Communications Director
  • Steven Thompson as Training Coordinator
  • Brenda McCormick as Director of  the Division of Healthcare Management
  • Norman Curtis as Director of Customer Service

Mr. Curtis was present at the meeting and given an opportunity to discuss his background and approach to customer service.  His most recent position was with MBNA where he was responsible for call centers.  He also announced that the provider relations staff will now be organized geographically, rather than  based upon policy assignments which had been the case recently. [return to top]

An Invitation to Participate in the Centers for Medicare and Medicaid Services' Physician Voluntary Reporting Program
There is much agreement among stakeholders about the need to transform the healthcare system and the imperative to build an efficient healthcare system that provides high quality care. The same stakeholders recognize that our current system is unsustainable in part due to a reimbursement model that rewards quantity of care and not quality. The pressure of ever increasing costs in the system are driving Congress, CMS, employers and private payers to look at payment mechanisms that reward  high quality, efficient care.  This includes rewarding healthcare professionals and systems of health care delivery that provide value and healthy outcomes for patients.   The expectation is to promulgate programs that seek to align reporting and payment structures with the physician professional goals of providing high quality care. The Physician Voluntary Reporting Program (PVRP) is a first step in that process. 

The CMS quality vision is of a system that rewards the right care for every person every time. Care should be safe, effective, efficient, patient-centered, timely and equitable. The PVRP has been designed to allow physicians to document when they provide high quality care that meets these goals. This vision crosses all boundaries where patients receive care including hospitals, home, nursing homes and in the outpatient setting.

Why should you commit to participate?

CMS is actively encouraging primary care and emergency medicine physicians, nephrologists and surgeons to commit to participating in this program.  There are a number of reasons that you should strongly consider doing so. These include:

  • It is an opportunity to assess your performance based on nationally established clinical measures and identify gaps in care.  In the hospital quality reporting initiative, those organizations that participated early benefited from learning about their performance prior to having payments attached to such a reporting program.
  • As Congress contemplates revising the SGR (the formula that determines the physician fee schedule update), physicians should recognize that there is interest in incorporating pay for reporting programs in any future revision of the PVRP.
  • To make this as straight forward as possible and to provide flexibility, you can utilize either G-codes or CPT category II codes that can be pre-listed on a worksheet to capture and submit this information for each patient encounter. The PVRP provides you the opportunity to utilize CPT II code modifiers to report specific patient exclusions based upon medical judgment, patient factors, or health care system circumstances that may impact physician choice of therapies.
  • Participation at this point will allow you to ensure that your medical records, office software and claims processing/billing system vendor can support the submission of this information to CMS now and in the future.
  • Finally, your participation in PVRP now will give you the opportunity to provide CMS with valuable feedback on what works and what needs improvement in the program. 

What is being measured in the program?

  • The program includes an initial core set of 16 evidence-based quality measures that are clinically valid and linked to quality of care outcomes.  PVRP measures were established nationally through a collaborative process across medical specialties. It is intended that the core set of measures will expand to include additional clinical conditions. 
  • For a complete list of all 16 measures, their specifications, and more information, please go to http://new.hhs.gov/pvrp
  • For sample worksheets by physician group, please go to 
  • Information on CPT category II codes is also available on the Web.  Please go to http://www.ama-assn.org/ama/pub/category/10616.html

How do you participate?

You can register your intent to submit data now.  Simply go to http://www.qualitynet.org/pvrpintent and register.  You can register individuals or groups on the site. 

You can then begin to submit data.  Sample worksheets to facilitate capturing data are available on the PVRP Web site.  These can provide a method for capturing the physician action that can then be coded and submitted to CMS through normal billing mechanisms.  Instructions for this process can also be found on the Web site. 

The sooner you begin submitting data during the Second Quarter of 2006, between April 1st and June 30th, the more feedback on the measures you will receive in December.  This data will be contained in a confidential provider feedback report.  The results can then be incorporated into your own quality improvement activities.

CMS Next Steps

Over the next few months, CMS will continue to build upon our quality measurement activities and increase the number of specialties addressed by further expanding the measure set.  Efforts will be made to allow this process to be part of our ongoing activities to move toward electronic healthcare records.  CMS will also be evaluating the value of the provider feedback report. [return to top]

Continuity of Care Record (CCR) Presentation by David Kibbe, M.D. - April 24, 3:00 pm
You are invited to attend a presentation by David C. Kibbe, MD, Director, Center for Health Information Technology, American Academy of Family Physicians on the Continuity of Care Record (CCR).  Dr. Kibbe's presentation is titled Continuity of Care Record: A New Standard for Personal, Portable and Private Health Information Exchange.  The one hour presentation will be given on Monday, April 24, 2006 at 3 PM at the Maine Medical Association Office in Manchester, Maine.  Seating is limited so we ask that you RSVP to Carla Thomas at the MHIC to reserve your spot  cthomas@mhic.org.  The Maine Medical Association is located on the same campus as the MHIC office.  Directions can be found at http://www.mainemed.com/about/directions.php.

The CCR will enable healthcare providers to base future care on relevant and timely patient information. It is a core data set of the most relevant and timely facts about a patient's healthcare, prepared by a provider at the conclusion of a healthcare encounter in order to enable the next provider to readily access such information. It includes a summary of the patient's health status (e.g., allergies, medications, vital signs, diagnoses, recent care provided) and basic information about insurance, advance directives, care documentation, and care plan recommendations.

HealthInfoNet (formerly known as MHINT) is dedicated to using national standards for the exchange of data. The CCR data elements transmitted using the ANSI approved HL7 v3 standards achieves that goal.  HealthInfoNet will adopt the data elements of the Continuity of Care Record (CCR), but not all in the first phase implementation.  Through recommendations from the Phase I Medical Advisory Group, the following CCR components are being considered for adoption during the first phase:

  • Patient identification information (including Next of Kin) 
  • Information regarding the patient's Advance Directives (including DNR status) 
  • Information regarding the patient's health status including:
    • Conditions, Diagnoses or Problems
    • Adverse Reactions/Allergies
    • Medications
    • Laboratory Results
    • Imaging (transcribed documents including imaging results)

Since the CCR will be such an integral part of HealthInfoNet, this is a unique opportunity for us to hear from one of the CCR developers about the standards as they now exist and plans for the future.

For background information on the CCR, I would refer you to the white paper written by Dr Kibbe titled "Unofficial FAQ of the ASTM Continuity of Care Record (CCR) Standard".  The web link is www.centerforhit.org/x1750.xml There are several other valuable documents documents the CCR on  www.centerforhit.org/x201.xml that provide informative background information on this topic.

We hope you will be able to join us.

Suanne Singer
President, Maine Health Information Center
Telephone: 207 430-0656
          Or   207 623-2555 x656
Fax: 207 622-7086
[return to top]

Will Your Senator Vote To Support Medical Liability Reform?
Protect Patients Now

On May 2, the U.S. Senate will vote on legislation to fix our nation's broken medical liability system. While the bill has not yet been introduced, Senate leadership has indicated that it will include reasonable limits on non-economic damages modeled after the successful reforms passed in Texas in 2003. The bill will be introduced as S.22, The Medical Care and Access Protection Act of 2006.

Doctors for Medical Liability Reform has created a new interactive report, documenting how Members of the Senate have voted on similar legislation over the past several years. While the House has repeatedly passed reform legislation, it continues to be blocked in the Senate. You can see if your Senators have supported reform in the past by viewing your Senators' voting history.

Also, please make sure you sign our online petition and remember to pass it along to as many friends, colleagues, neighbors, family members and patients as you can. Our petitions will be delivered to Members of the Senate, along with the message that physicians, patients, and concerned citizens nationwide want to end medical lawsuit abuse.

We'll be sure to keep you updated as this issue develops. Thank you for your continued support.


Doctors for Medical Liability Reform
317 Massachusetts Ave., N.E.
Suite 100
Washington, DC 20002
Phone: 1-887-9REFORM
[return to top]

Judge Orders Timely Decision by Dirigo Board for 2007 Savings Offset Payment
In a decision issued Friday, April 14, Superior Court Justice Donald Marden ordered the Dirigo Health Board of Directors to establish the "savings offset payment" for the year 2007 by May 12.   The decision came in a lawsuit filed by health insurers and the State Chamber of Commerce which sought the action after the agency missed its statutory deadline of April 1.

Under the original Dirigo legislation, the Board is required to determine by April 1 each year "the aggregate measurable cost savings, including any reductions or avoidance of bad debt and charity costs to health care providers" resulting from the operation of Dirigo Health.  The Board had decided to wait until later in the year (after August) before establishing the SOP for next year, but insurers and the state chamber of commerce filed the lawsuit claiming that they would be injured by the delay and that the delay was not authorized by law.   Justice Marden agreed with the insurers.

It is not clear whether the Dirigo Board will appeal the decision to the state Supreme Judicial Court.

The "savings offset payment" has been the most controversial part of the Governor's Dirigo Health initiative.  While the payment made theoretical sense given the anticipated coverage of virtually all the uninsured, many observers and impacted parties have questioned the impact of DirigoChoice on bad debt and charity care when less than 10,000 individuals are covered by the plan currently.

The legislature still has under consideration proposed legislation, supported by the Governor and consumer interests, which would prohibit insurers from passing the SOP on to premium payers (L.D. 1935). [return to top]

DirigoChoice Update
The Dirigo Health Board of Directors met on Friday and heard reports on the current status of the DirigoChoice product.  As of the end of March, the plan covered 9473 persons, with 30% being classified as sole proprietors, 32% individuals and 38% small groups. 

The Board also received a list of high expense/risk categories based upon paid claims from the past twelve months.  Among the higher expense categories were:

  • mental Health disorders
  • angina pectoris
  • coronary occlusion
  • heart disease
  • juvenile diabetes
  • metastatic cancer
  • multiple sclerosis
  • HIV/aids

The loss ratio remains fairly positive (about 76.5%) with the individuals and sole proprietors having a higher loss ratio than those individuals enrolling through a small business.

It was also reported that Jonathan Beal, a Portland attorney and Ned McCann, a well-known State House labor activist, have been nominated by the Governor to replace Board members Mary Henderson and Carl Leinonen whose terms have expired.  The other voting Board members are Robert  McAfee, M.D. (Chair), Dana Connors and Charlene Rydell. [return to top]

MMA Payor Liaison Committee Meets with Anthem Officials
On Thursday, April 13th, MMA's Payor Liaison Committee met with Anthem Medical Director Jeffrey Holmstrom, D.O. and Amy Cheslock, Executive Director of Provider Network Management for Anthem.  Previous to her replacing Dan McCormack as head of network management, Ms. Cheslock was responsible for hospital contracting for Anthem.  Before coming to Maine approximately one year ago, she had worked for United Health Care in Rhode Island.

The discussion involved various topics, including the existing Quality Insight program, which utilizes specific patient data to promote disease and case management programs. This current Pay 4 Performance program will reward primary care physicians with increases of 2,4, or 6% based upon data submitted for 2005.  The updates will be effective July 1, 2006.  Although the numbers are not final, Dr. Holmstrom indicated that the vast majority of eligible physicians were presenting some data through the web portal.  For the next year, Anthem will make an attempt to get closer to the measurements being done by Pathways to Excellence.  He noted that there is about a 92% overlap between the two programs currently.

Anthem has announced an increase to the conversion factor of 1%, effective July 1.  Committee members expressed disappointed with the small increase, noting that the increases the last two years were 3% annually.  In response to this, Jeff and Amy noted that when Wellpoint and Anthem merged, the Wellpoint fee schedule for physicians was 85% of Medicare and the Anthem fee schedule was 130% of MaineCare.  While company officials can understand some of the unique needs of the northeast, further increases are likely to be small.

In response to a question, Amy indicated that provider relations and network staff have been fully briefed on the provisions of the consent decree which settled the federal multi-district class action suits against Anthem and other health plans.  There are several provisions of the decree designed to make the communications between the plans and providers more transparent.

The Committee will meet next on June 29th at 6:30pm with dinner available at 6:00p.m.

  [return to top]

MMA Quality Committee Meets with MHA Representatives
Deborah Johnson, CEO of Eastern Maine Medical Center, and Chair of the Maine Hospital Association's Quality Council, and Sandra Parker, J.D., who staffs the Council, met with MMA's Committee of Quality Improvement and Peer Review last week.

The MHA representatives asked for the assistance of the MMA Committee in inviting physicians to join Maine hospitals in an effort to have every patient carry a current accurate list of their medications.  MHA shared their medication brochure which can be customized for each practice.

In addition, MHA also asked the Committee to join the hospitals in working on heart attack, heart failure, pneumonia, surgical infection prevention, culture of safety, patient satisfaction and the IHI 100K lives campaign.  These initiatives will be presented to the MMA Executive Committee on April 26.

Committee members discussed other potential ways to collaborate with the MHA Quality Council, including the possibility of each Chair serving on the other organization's Committee ex-officio. [return to top]

MMA to Present CME Program on Preventing Drug Diversion in Presque Isle on Saturday AM
On this coming Saturday morning, April 22, The Maine Medical Association and the Maine Office of Substance Abuse (OSA) will present a three-hour CME program entitled, "Preventing Prescription Drug Abuse," at The Aroostook Medical Center in Presque Isle.  The program will feature the head of the local drug enforcement task force outlining the problem, OSA staff discussing the state's relatively new Prescription Monitoring Program and MMA EVP Gordon Smith Esq., detailing steps a practice can take to minimize risk and legal issues regarding confidentiality.

The program will run from 9:00am to noon in the education room at TAMC.  There is no charge, but persons wishing to attend should call Tammara Race at TAMC.  The program is offered at no charge because OSA has given a grant to MMA to do eight programs of this type around the state this year.  Practices, FQHC's, hospitals or other facilities wishing to hold one of the programs at their location should contact Gordon Smith at gsmith@mainemed.com. [return to top]

The Coding Center's Coding Tip of the Week
Can I code 99211 when I give an injection i.e. a flu shot if I also am checking vitals?
You should not use the 99211 when delivering a flu shot if you are taking routine vital signs. Verifying that a patient is "OK" for a flu shot and checking on the patient  before they leave the office are components of the administration code. There are many payers that will not pay for code 99211 in conjunction with an injection code for just this reason. In this case, code just for the appropriate administration code (90471-90472) and the flu vaccine.

Questions? Call the Coding Center: 1-888-889-6597. [return to top]

Common framework for Health Information Sharing Released

Connecting for Health, a public-private collaborative of more than 100 organizations, has released a "Common Framework: Resources for implementing private and secure health information exchange." The report provides the initial elements of a comprehensive approach to secure, private health-care data sharing that provides patients and their authorized providers with access to clinical data when and where they are needed. It includes 16 technical and policy components, such as technical specifications, privacy and security policies and model contractual language. A key function of the framework is to enable a diverse group of existing and developing networks to have a common way to share health information. For more information, including a link to an informational video and downloads of the materials, visit: www.rwjf.org/newsroom/newsreleasesdetail.jsp?id=10405

[return to top]

MMA to Present Program on End-of-Life Care at CMMC on Tuesday noon, April 25
On Tuesday, April 25th, at noon,  MMA will present a one-hour CME program at Central Maine Medical Center in Lewiston on the topic of,  "Improving End of Life Care through Advanced Directives."  The presentation will be by EVP Gordon Smith Esq., who will discuss the current laws regarding the use of advanced directives, the evolution of the law and ethical provisions during the last twenty-five years, and the new law passed by the state legislature last month.

There is no charge for the program which will be presented in Chairman's rooms A & B. [return to top]

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