August 28, 2006

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MaineCare Backs Off Aggressive Repayment Plan

MaineCare officials are now re-thinking a draft plan which would have recouped all the interim payments held by physicians (and other providers) by July 1, 2007 through automatic withholding of payments.  MMA had strenuously objected to the plan, noting that there is more money owed to physicians in the suspended claims file than physicians owe in interim payments.  Future fixes of MECMS have been pushed back because of the poor performance of "Release 1."

The draft plan to recapture all remaining MaineCare interim payments  in a global recovery effort has been shelved for now but could resurface if the remaining funds outstanding are now returned at the rate hoped for by the state.  Physicians who recieved interim payments because of the MECMS issue and have not been contacted previously, will receive a letter within the next  30 days describing various alternatives designed to recapture most of the amount outstanding by July 1, 2007.

MMA representatives had strongly opposed the plan, noting that collectively physicians were owed more in suspended claims ($37 million) than they owed in interim payments ($13 million).  We also objected to the notion of collecting all the outstanding payments prior to the date at which the MECMS system would be complete.  As the future "Release" dates have been pushed back, it is unkown when certain functions such as electronic payment of the Part B crossover claims will be fixed. 

"Until the MECMS system is functioning at an acceptable level, it is premature to be talking about return of the interim payments", noted Gordon Smith, Executive Vice President of MMA.  "We are now over a year and a half into this mess and every time a step is taken forward, it seems as if  two steps are taken back", he added.

After announcng the possible global recovery effort at the Governor's Provider Advisory Committee meeting last week, the automatic recovery was not mentioned in a presentation to the Legislature's Appropriations Committee on Thursday afternoon.  When MMA staff sought to clarify whether there had been a change of heart, Deputy Commissioner Kristen Figuerora said that the original plan had just been a draft and that MaineCare would first focus on the 2005 claims hold rather than moving now on any global recovery effort, at least from physicians.  She noted that there is sensitivity to the fact that collectively there is more money in the suspended claims file (owed to physicians) than there is funds owed back by physicians from interim payments for claims which have been subsequently paid.

The Provider Advisory Committee scheduled for August 31 has been cancelled.  The next meeting will be held on Thursday, September 14.



"Medicine in Extreme Environments" Theme of 153rd Annual Session Next Week

"Medicine in Extreme Environments" is the theme of the CME portion of the 153rd Annual Meeting of the Maine Medical Association being held Sept. 8-10 at the Fairmont Algonquin Hotel in St. Andrews By-the-Sea, New Brunswick, Canada.  Keynoting the program is former NASA astronaut and flight surgeon Story Musgrave.  Dr. Musgrave flew on each space shuttle and has an electrifying presentation that will be presented at 1:30pm on Friday, Sept. 8.

The CME program includes presentations on medicine in space, under seas and in high altitudes.  Volunteering for medical relief missions also qualifies as "medicine in extreme environments" and several physicians who performed services related to hurricane Katrina, the earthquake last year in Pakistan and in response to the tsunami in the far east will speak at the meeeting.  Six hours of category  one CME will be available.

About a dozen rooms are still available at the group rate at the hotel for Friday and Saturday night.  Hotel reservations can be acquired by calling 1-800-441-1414 and registration can also be done on line at the MMA website at

It is quite remarkable that MMA has held an annual meeting every year for 153 years.  We invite you to be a part of this one.

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Vountary Practice Assessment Project Looking for Chart Reviewer

The MMA-MOA project funded by the Maine Quality Forum designed to assess the quality of care provided to a subset of patients in 50 primary care practices is seeking to contract with a nurse or other experienced health care provider who may be interested in part time work between now and May 1, 2007.  The work involves conducting a confidential practice self-assessment based upon quality metrics for certain conditions developed by an advisory committee of physicians.  Approximately 35 charts will be reviewed in each practice. 

An hourly stipend and travel expenses will be paid.  The position will report to the Project Manager, Jean Eichenbaum, who was recently hired to direct the Porject.  Jean also serves as staff to Quality Counts!

Persons interested in this type of work should communicate with Jean at

The practice assessments will be conducted this Fall and through the winter, with the project expected to be completed by May 1, 2007.  Lisa Letourneau, M.D., MPH is the physician consultant to the project. [return to top]

Hanley Center for Health Leadership Invites Nominations for '06 Hanley Leadership Award

The Daniel Hanley Center for Health Leadership is pleased to invite nominations for the 2006 Hanley Leadership Award.

Each year, the Award recognizes a healthcare professional who embodies Dr. Dan Hanley’s principles of courage, innovation, collaboration, kindness and hard work. Learn more about Dr. Hanley and his work at

Previous Hanley Award winners have included Stephen Shannon, D.O, M.P.H., former Dean of the University of New England College of Medicine (2003); nationally known medical researcher John Wennberg, M.D., M.P.H., Chair of the Center for the Evaluative Clinical Services at Dartmouth Medical School (2004); and Franklin County clinicians Sandra Record, R.N. and Burgess Record, M.D. (2005).

We encourage nominations for individuals whose work has led to improved health and healthcare at the community, regional, state or national levels; nominations are encouraged from small and large communities across Maine.

Although previous winners are well-known at state and national levels, we are anxious to receive nominations for individuals who are making a difference in your organization and/or community (see attached criteria for details). Nominees may be clinicians, administrators, board members and others.

It takes just a few minutes to complete and return the attached two-page nomination form---just print form, provide examples that illustrate your nominee's achievements and then mail the form---along with your nominee's resume or bio;  deadline is September 4.

If you've previously nominated a colleague for the Hanley Award, there is no need to complete another nomination form---simply notify Jim Harnar at and provide an updated resume or bio.

Former U.S. Senator George Mitchell will keynote the October 14 Hanley Award Luncheon at Bowdoin College and will participate in the award presentation.  Please mark your calendar today and plan to attend.  You will receive separate announcement.

The Hanley Center is pleased to announce that the 2006 Hanley Award Luncheon will be sponsored exclusively by KeyBank.


Deadline for Applications is September 4, 2006
Awards Luncheon is Friday, October 13, 2006 at Bowdoin College

FOR MORE INFORMATION: Contact Jim Harnar at [return to top]

Study: Pay for Performance Programs May Have Unintended Consequences

A study in the current Annals of Internal Medicine examining the impact of pay-for-performance programs finds that such incentive programs can have some unintended effects. In a review of 17 relevant studies published from 1980 through 2005, researchers found, for example, that better pay for improving measured performance could prompt physicians to avoid the most severely ill patients, thus restricting access to care for this group. A study on nursing homes revealed “strong incentives to ‘game the system,’ that is, manipulate the program to increase payment.” Researchers also noted that while an incentive might save the provider money, none of the studies found that the financial incentives were cost-effective to the health care system.  The authors suggest that performance measures should be created to produce both overall improvement and achieve a specific threshold and goal, that ongoing monitoring of incentive programs is critical and that controlled research trials would offer guidelines in developing and implementing financial incentives for health care quality. For more information:
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President Bush Issues Executive Order on Health Care Pricing and Quality

President Bush on August 22 signed an Executive order designed to help people make more informed decisions about physicians and hospitals.  Four different federal agencies will be required to compile information about the quality and price of care they pay for and share that information with their customers and each other.

The order directs the agencies to:

  • Use, when available, health information computer systems that can talk to each other.  Agencies will also require that providers doing business with the government purchase products that meet the same standards for data sharing.
  • Enact programs that measure the quality of care and develop those measures with the private sector and other agencies.
  • Make available to beneficiaries the prices that agencies pay for common procedures.
  • Develop and identify practices that promote high-quality health care.

The agencies affected by the executive order are the Health and Human Services Department, the Defense Department, the Veterans Affairs Department and the Office of Personnel Management.  A draft of the order says agencies must comply by Jan. 1, but HHS Secretary Mike Leavitt said the programs must be under way by that point, rather than completed.

The federal government pays for nearly 40% of the health care provided in the country. [return to top]

Study: Care of Medicaid Patients Concentrated Among Fewer Physicians

According to a survey by the Center for Studying Health System Change, care of Medicaid patients is becoming concentrated among fewer physicians who tend to practice in large groups, hospitals, academic medical centers and community health centers. The relatively low payment rates and high administrative costs seem to influence the decreasing involvement with Medicaid patients among solo and small group practices. From 1996-97 to 2004-05, the only significant change in Medicaid acceptance rates occurred among surgical specialists. In 2004-05, 18.8 percent of surgical specialists reported they were accepting no new Medicaid patients, compared with 13.9 percent of these physicians in 1996-97. Among physicians accepting no new Medicaid patients in 2004-05, about five out of six (84 percent) cited inadequate reimbursement as a moderate or very important reason for not accepting new patients.  Billing requirements and paper work were cited by 70 percent of physicians as reasons for not accepting new patients, while about two-thirds cited delayed reimbursement. To download the full study:  
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Survey: Public's Views of What Health Care Should Be Don't Match Reality of Their Experiences

A new survey of more than 1,000 adults by the Commonwealth Fund finds that, while 94 percent of those surveyed consider it important to have easy access to their own medical records, only about half report that they do have such access. Additionally, although 92 percent of those surveyed think it's important that care from different doctors is well-coordinated, 42 percent report having received poorly coordinated, inefficient or unsafe care during the last two years. This includes unnecessary care or treatment recommended by a doctor, failure to provide important information or test results to other doctors or nurses, medical errors, or duplicate tests. Survey participants also supported expanded use of information technology and a “medical home,” one place or doctor responsible for providing and coordinating all medical care. For more information:
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Senate President Seeks Physician Interested in Human Trafficking Issues for Task Force

The President of the Maine Senate, Beth Edmonds (D-Cumberland), is seeking a physician interested in working on the problem of human trafficking for service on a Human Trafficking Task Force created during the last legislative session by L.D. 1296, Resolve, to Create the Human Trafficking Task Force (Resolves 2005, Chapter 200).  You can review the Resolve on the web at:  The Task Force is expected to meet through the Fall & make its recommendations to the 123rd Maine Legislature by the end of the year.

If you are interested in serving on this Task Force, please contact Charyl Smith, Legislative Assistant, at  [return to top]

Anthem Sponsors Workplace Wellness Conference on 10/19/06 in Augusta

Employers of all size businesses in Maine are becoming more and more interested in implementing a workplace wellness program to control spiraling health care costs. An upcoming conference on Oct. 19 will focus on how to get a workplace wellness program started or make a current program more effective.

The statewide conference on “the business case for workplace wellness” will explore what employers can do to help their bottom line and their employees’ health through a well-designed workplace wellness program.

The conference will take place at the Augusta Civic Center and is part of a series of conferences sponsored by Anthem Blue Cross and Blue Shield called “Reversing the Tide: Creating a Healthier Maine.”

The conference will bring together both national and state experts on workplace wellness programs and Maine business leaders who have implemented programs at their own companies with positive results.

Two of the nation’s foremost experts on workplace wellness will deliver keynote addresses: Dee Edington, PhD, Director, Health Management Research Center, University of Michigan and Michael O’Donnell, PhD, President and Editor-in-Chief, American Journal of Health Promotion.

A panel of Maine business leaders will discuss how workplace wellness programs help their companies achieve results. The panel will include Pete Vigue, CEO of Cianbro, Dan  Dauphinee, Operating Manager, Northeast Log Homes and Kathi Teel, Bangor Regional Wellness Council and co-owner Castine Boat Company.

Larry Catlett, MD, of Occupational Medical Consulting will speak about the key role behavior change plays in improving employee health.

Afternoon breakout sessions will include tracks on how to start a workplace wellness program and ways to improve a program already in place.

The conference brochure and online registration will be available at beginning September 1. The conference is open to all participants but space is limited and pre-registration is required. [return to top]

Dirigo Board Approves 2007 DirigoChoice Plan Design

The Dirigo Health Program Board of Directors spent its most recent regular meeting on August 21, 2006 considering Executive Director Karynlee Harrington's recommended changes in the DirigoChoice plan design for the coming year.  While some have criticized the DirigoChoice product for its premium level if one does not qualify for a subsidy, Ms. Harrington warned that it would be risky to make radical changes in the plan design based upon one year of data.  Accordingly, she recommended a short-term strategy for the next 12 months that would provide some premium relief. 

The proposed 2007 plan design, accepted unanimously by the Board, is described below:

  • Deductible Single.  $1250/$1750/$2500
  • Deductible Family.  $2500/$3500/$5000
  • Out of Pocket Single (including deductible).  $4000/$5600/$3500
  • Out of Pocket Family (including deductible).  $8000/$11200/$7000
  • Preventive Care Office Visit.  100% for all plans
  • Office Visit Copayment.  $25 for all plans
  • Rx Copayment.  $10/$30/$50 for all plans
  • Maintaining 100% coverage for preventive office visits while increasing all other office visit copayments by $5 and increasing Rx copayments for brand and optional brand allows for an approximate reduction in the 2007 monthly coverage cost of 4.4%
  • Dual options ($1250/$1750 or $1750/$2500) will be available for small groups (2-50)
  • $1750 and $2500 will be available for individuals & sole proprietors
  • Approximate reduction in monthly coverage cost moving from $1250 to $2500 is 11%
  • Approximate reduction in monthly coverage cost movming from $1750 to $2500 is 2.8%

The Board's next regularly scheduled meeting is Monday, September 11, 2006 at 1 p.m. at the Dirigo Health Agency office, 211 Water Street, Augusta. [return to top]

The Coding Center's Coding Tip of the Week

Medical Decision Making (MDM)  This is the physician’s thought process quantified.

  • It is okay to document Rule-out or suspected diagnoses (can never use these to code the claim) in your assessment and plan, this helps support the thought process and adds to level of complexity
  • 2 of 3 areas of MDM (# of Diagnosis, Data and Risk) must be met or exceeded to reach level of MDM
  • The “Data Reviewed” area is where most physicians do not give themselves credit by documenting  the work they have done 
  • Things that count that rarely get documented:
    • Review of chart – not enough to say chart reviewed must comment on what was pertinent from that review
    • Obtaining History from someone other than patient. If Mom in exam room with 12+ year old and provides additional info, that counts. So do husband and wife who both give history.

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

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