August 14, 2006

 
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Dirigo Blue Ribbon Commission Holds First Meeting

The Governor's twenty member Blue Ribbon Commission on Dirigo Health held its first meeting on Wednesday, August 9 and established rules for its work between now and December 15 when it is due to report back to the Governor.  MMA EVP Gordon Smith, DirigoHealth Board Chair Robert McAfee, M.D. and retired Fort Kent surgeon Peter Toussaint, M.D. are members of the commission which hopes to find alternatives to the current funding source for the DirigoChoice product.

The Governor's cabinet room was the location of the first meeting of the Blue Ribbon Commission on Dirigo Health last Wednesday.  The commission was created by Governor Baldacci pursuant to an Executive Order issued on May 24, 2006 in the waning hours of the second regular session of the 122nd Legislature.

The 20-member commission is charged with (1) reviewing and making recommendations for alternatives for funding the Dirigo Health Program and the subsidies under the program in a fair, equitable and broadly distributed manner and (2) reviewing and making recommendations on methods proven effective in reducing and controlling health care costs and create savings in Maine's health care market, including how such methods may be incorporated in the DirigoChoice health insurance product.

Governor Baldacci joined the meeting at lunchtime and thanked members and Chair Sandra Featherman,  PhD. for their willingness to serve on the commission. "Health care is an important issue, not just in terms of Dirigo, but in terms of the economy and the environment and poses challenges not only to the state but also to the nation,"  the Governor told the commission.  He expressed support for the recent Superior Court decision rejecting a challenge to the so-called Savings Offset Payment (SOP) but also said he was looking to the future and hoped to find alternative means of funding efforts to increase the number of Mainers purchasing DirigoChoice.

The substance of the meeting consisted of each commission member stating their initial thoughts on the goals of Dirigo and their hopes for the commission work, as well as a discussion of the rules that will govern the group's deliberations.

The next meeting of the commission will be held on Sept. 7.  The Governor expects to have the commission's recommendations in hand by December 15, in time for consideration by the next Legislature.

New Medicare Physician Pay Rule Released by CMS; Decrease of 5.1% Anticipated

The evening of August 8, CMS released a second 2007 Medicare physician payment schedule proposed rule.  In June, CMS issued a proposed rule that addressed the 5-year review of physician work values and changes in the practice expense values.  The August 8th rule addresses imaging cuts and other changes in payment policies for 2007.

Due to changes in the calculation of the Medicare Economic Index (MEI) for 2007, the update is now forecast by CMS to be an even deeper cut of negative 5.1% instead of the negative 4.7% update projected in the Medicare Trustees report.

This steeper cut increases the urgency of rapid action by Congress to stop the cut and provide a positive update.  It is critical that the entire physician community mobilize to present a unified message to all Members of Congress that this pay cut is unacceptable.

The AMA press release on the payment rule follows below.  We are in the process of developing an analysis of the rule that will be disseminated to you soon.

MEDICARE PHYSICIAN PAYMENT RULE AGAIN POINTS TO NEED TO REFORM PAYMENT SYSTEM; CONGRESS MUST STOP CUTS

CMS Now Projects Deeper Physician Payment Cut of 5.1% for 2007

 

Statement Attributable to:           Cecil B. Wilson, M.D., AMA Board Chair

“This latest Medicare physician payment rule again highlights the need to fix the fatally flawed physician payment system, with next year’s Medicare physician payment scheduled to be cut 5.1 percent.  Seniors who rely on Medicare and the physicians who care for them are stuck wondering if 2007 will be the year access to care erodes as we wait for congressional action to stop the Medicare payment cuts.

“Medicare has expanded the treatments it covers more than 90 times since 1999, yet under the current Medicare payment system physicians are penalized with lower payments per service the more care they provide.  In fact, Medicare currently reimburses physicians about the same in 2006 as it did in 2001.  Without congressional intervention, Medicare physician payments will be slashed 37 percent over the next nine years, as practice costs increase 22 percent.  Nearly half, 45 percent, of physicians tell the AMA the cuts will force them to either decrease or stop taking new Medicare patients.  To keep providing high quality care to patients, Medicare must provide appropriate payments to the doctors who provide that care.

"This latest Medicare rule imposes cuts on imaging services that are used by physicians to make specific and accurate diagnoses of patient illnesses.  As advances in imaging technology increase the ability to provide quality, targeted care, more patients and physicians rely on these services.  It is important to look not just to the increase in use of such services, but to their ability to provide patients with healthier outcomes, such as using CT scans and MRIs to pinpoint and stage various types of cancer.  Medicare must differentiate between appropriate and inappropriate imaging use and tailor its policies so that appropriate use is not punished.  In fact, many of these services have been encouraged through new Medicare screening benefits, such as bone density measurement to prevent osteoporosis.  These imaging cuts would impact patients ability to get quality diagnose through imaging services and should not be implemented.

“The AMA calls on Congress to stop next year’s Medicare physician payment cut and instead reimburse physicians in line with increases in the cost of caring for America’s seniors.” [return to top]

MMA Website Security Enhancements

As we continue to enhance the Maine Medical Association's website, www.mainemed.com, we are also enhancing the security of the site.  In order to do this, the new member registration area will be non-accessible during implementation starting this week.  Those members already with access (usernames/passwords) will not be affected until the new system is activated.  As soon as some modifications to the members-only registration area are made, ALL members will need to re-register using the new registration process.   All members-only registrations will require MMA's approval.  

We apologize for this inconvenience, but it is necessary in order for us to continuing to bring you valuable information in a secure manner.  Should you have any questions or experience any difficulties, please feel free to contact Shirley Goggin at 207-445-2260 or sgoggin@mainemed.com.  Thank you for your patience during this process. [return to top]

Event for Senator Olympia Snowe Tuesday in Bangor

MMA members and friends are reminded of the event being held for U.S. Senator Olympia J. Snowe on Tuesday, August 15 at the Penobscot Valley Country Club from 6:00pm to 7:30pm.  The cost is $100 per person with the proceeds benefiting the re-election campaign of the Senator.  Physician hosts include Krishna Bhatta, M.D., Thomas Palmer, M.D., Stephanie Lash, M.D., John West, M.D., John McGill, M.D. and Francis Kittredge, M.D.  Additional hosts include Gordon Smith and Andrew MacClean.

Senator Snowe will make brief remarks and will address the current status of the attempt in Congress to fix the Medicare physician payment  formula.  Without a fix, CMS will be decreasing fees in January, 2007 by 5.1%. [return to top]

FPA Offers Training on Emergency Contraception

The Emergency Contraception AT THE COUNTER Project is hosting informational sessions on the:

  • collaborative practice agreement process;
  • latest information on emergency contraception and the status of Plan B; and,
  • important role you play as part of the team providing increased access and options for Maine women.

These forums are specifically created to accommodate your busy schedules as health care providers and will update you on emergency contraception activities throughout Maine. We offer individual and group sessions. Credits have been applied for.

Log on to www.mainefamilyplanning.org and click on the Emergency Contraception links for more information.

Please call Cheryl Daggett WHC, NP at 622-7524 to schedule a session or to answer any questions.

The Family Planning Association of Maine's Emergency Contraception AT THE COUNTER Project is funded by a grant through the Maine Health Access Foundation.
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American Heart Association, Northeast Affiliate, Maine Division Announces 57th Annual Maine Scientific Session

57th Annual Maine Scientific Session -- The Metabolic Syndrome & Coronary Risk
02/10/2007 -- 02/11/2007

Location:
Samoset Resort
220 Warrenton Street
Rockport, ME 04856

The American Heart Association, Northeast Affiliate, Maine Division is extremely proud to announce the 57th Annual Maine Scientific Session.  For over fifty years this conference, which has a national reputation within the American Heart Association, has attracted a large percentage of Maine's cardiologists, cardiac surgeons, internists, family practitioners and coronary care nurses, as well as other health professionals.  In addition to the exceptional education program, the Scientific Session offers an excellent exhibition area and ample opportunity to interact with the attendees.

We are very pleased to announce that Dr. Robert H. Eckel, President of the American Heart Association, a Charles A. Boettcher Endowed Chair in Atherosclerosis and Professor of Medicine, Physiology and Biophysics at the University of Colorado Health Sciences Center, is this year's Drake Award recipient.  This day and a half program will include other distinguished healthcare practitioners who will address a variety of topics related to the metabolic syndrome and coronary risk.

For more information contact:
Melissa Goodrich, Director, Scientific Session, Northeast Affiliate
207-523-3002
melissa.goodrich@heart.org
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The Doctors Company Files For Professional Liability Insurance Rate Increase

On July 12, 2006, The Doctors Company of Napa, California filed with the Bureau of Insurance a medical malpractice rate increase request averaging 8.8%.  The company has 24 policyholders in Maine representing $455,148 in written premium.  The proposed effective date is September 1, 2006 for new policyholders and November 1, 2006 for renewals.

The company's last rate request was for an average 29.2% increase in 2004.

This rate request includes a range from a maximum percentage change of 18.4% to a minimum percentage change of -4.8%.  The following is a representative group of rate changes by specialty:

  • Anesthesiology - Pain Management:  49.8%
  • Hand & Foot Surgery:  -15.9%
  • Neurosurgery:  32.4%
  • Occupational Medicine:  -4.8%
  • Ophthalmology - No surgery:  -20.4%
  • Orthopaedic surgery - No spinal:  -0.7%
  • Psychiatry:  -8.2%
  • Therapeutic Radiology:  -46.7%
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Nominations, Resolutions Solicited for 153rd Annual Meeting Sept. 11, 2006

MMA members are invited to submit resolutions and nominations for consideration by members at the Annual Meeting to be held this year at the Fairmont Algonquin Hotel in St. Andrews-by-the-Sea, New Brunswick, Canada Sept. 8-10.  During the weekend meeting, which begins at noon on Friday, Sept. 8, the general membership meeting will be held on Sunday morning, Sept. 11 beginning at 8:00am.  Members in attendance will vote for various resolutions submitted, elect officers and adopt a budget for the new year.  Attendees will also hear reports from MMA officers and committee chairs, as well as special updates from Medical Mutual Insurance Co. of Maine and the Maine Centers for Disease Control and Prevention.

Resolutions should be submitted Sept. 1 to Gordon Smith at MMA (gsmith@mainemed.com).  Nominations should be submitted to Kevin Flanigan, M.D., chairman of the Nominating Committee at flanmansvpc@pol.net.

Members needing hotel reservations should call the Fairmont at 1-800-441-1414.  Members may register for the meeting on the MMA website at www.mainemed.com.  The hotel roomblock expires on August 21 so members are encouraged to make their hotel reservations this week. [return to top]

MaineCare Soliciting Input on Ways to Improve Prior Authorization on Non-drug Requests

As part of the transformation of the Office of MaineCare Services, Deputy Commissioner of DHHS has initiated a comprehensive review of MaineCare's prior authorization requirements.  To assist in the effort, OMS has engaged a team of national experts to review the current PA rules. Their analysis will benchmark the PA requirements against prevailing and best practices in the commercial health insurance industry, examine the cost effectiveness of current rules and recommend changes for bringing the PA process into the 21st Century.

The intent is to align MaineCare's prior authorization process with industry standards, to use criteria that  are largely consistent with the familiar practices you encounter when dealing with other health insurance carriers, eliminate PA requirements that are irrational, and significantly reduce the administrative burden on the MaineCare provider community.

The current PA requirements for the following services are being scrutinized:

  • Physician and Diagnostic Services
  • Durable Medical Equipment and Hearing Aids
  • Vision and Dental Services
  • Out-of-State Services
  • EPSDT
  • Transportation Services
  • Other Professional Services

With each of the numerous PA requirements within these broad service areas, OMS is seeking any suggested improvements in the process of seeking prior authorizations - including outright elimination of a particular requirement if that makes the best sense to you from a clinical or economic perspective.

Suggestions including a brief explanation of  the basis for it should be sent to Lucille.Weeks@maine.gov or write to Division of Policy, Office of MaineCare Services, 11 State House Station, Augusta, Maine 04333-0011. [return to top]

Reminder: Legal Services for the Elderly Offers Help with Medicare Part D

MEDICARE PART D APPEALS UNIT: LEGAL SERVICES FOR THE ELDERLY

When your patients need help because their Part D Prescription Plans refuse to cover their prescribed drugs you can refer them to:

Medicare Part D Appeals Unit, Legal Services for the Elderly (LSE), Augusta, Maine
Toll Free: 1-877-774-7772

Calls taken Monday through Friday, 9 a.m. to Noon, and 1 p.m. to 4 p.m. MaineCare and Low Cost Drugs for the Elderly members with appeals when their Part D Drug Plans deny coverage of their medication. The Unit will also help physicians and their staffs in filing coverage determination requests and in obtaining any needed Part D information. There is no cost for this help.

Common reasons for denial of coverage that are subject to appeal  include:

  • The Plan takes the position that the prescribed drug is not medically necessary.
  • The medication is a Part D drug, but is not on the Plan’s formulary.
  • The Plan requires Prior Authorization and it was denied or not obtained.
  • The prescribed dosage is not covered by the Plan.
  • The prescribed form (liquid/pill/injectable) or type (generic/brand name) of the drug is not covered by the Plan.
  • The Plan is requiring step therapy.

In addition, when a patient cannot afford the co-pays for drugs (and the patient is not in the “donut hole”) the Appeals Unit may be able to obtain a reduction in the co-pays (a “tiering exception”).

Physicians and their Staffs can also call the Part D Unit for information and for fax/phone numbers for the Part D Plans. Information is also available at the LSE website: http://www.mainelse.org/

 Background
Legal Services for the Elderly has provided free, high quality legal services to Maine’s socially and economically needy seniors since its establishment in 1974. The Medicare Part D Unit was started in 2006 under a contract with the State of Maine. [return to top]

The Coding Center's Coding Tip of the Week

History Documentation Makes a Difference:

  • Detailed History = HPI 4+, ROS 2-9, PFSH 1
  • Comprehensive = HPI 4+, ROS 10+, PFSH 3
    • Codes that  require a Detailed History = level 3 new patient and consult services, low level admits, high level subsequent care codes, level 4 established patient visit codes.
    • Codes that require a Comprehensive History = level 4 and 5 new patient and consult services, level 2 and 3 admits, level 5 established patient visit codes.
    • All three elements must meet or exceed the level exactly
    • Failure to document one element of the History appropriately automatically drops the entire History level.
    • Failure to document 10 ROS drops to the level of History to Detailed (HPI 4, ROS 9, PFSH 3 = Detailed)

Questions? Call the Coding Center: 1-888-889-6597.
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For more information or to contact us directly, please visit www.mainemed.com l ©2003, Maine Medical Association